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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005738
Report Date: 09/22/2024
Date Signed: 09/23/2024 07:24:33 AM

Document Has Been Signed on 09/23/2024 07:24 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:INSPIRING CAREFACILITY NUMBER:
397005738
ADMINISTRATOR/
DIRECTOR:		WILLIAM PUCKETTFACILITY TYPE:
735
ADDRESS:2488 NATHANIEL STREETTELEPHONE:
(209) 951-2405
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 5CENSUS: 2DATE:
09/22/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Devon Gaines TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 09/21/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a Health and Safety Visit. LPA met with Staff member, Devon Gaines and explained the purpose of the visit.
The purpose of this visit to conduct a health and safety visit. LPA asked that SM Gaines call the Facility Designated Administrator (FDA) to inform them that CCL was present. LPA Pascua continued the visit with SM Gaines.

Current census was 2. 2 out of 2 residents were out of the facility at this time.

LPA toured 4 resident bedrooms. 2 of 4 resident bedrooms were occupied. All rooms are were observed to meet the resident's needs at this time.
Living area, dining area and other resident areas were observed. Furniture was observed to be in good repair.
LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply at this time. Additional perishable food supply was identified and observed in the garage freezer and refrigerator.
LPA was able to confirm that all residents have eaten and have snacks accessible at all time.

Toxins were observed to be locked and made inaccessible. Hot water was within the required range at this time. Smoke detectors and carbon monoxide was observed to be in good repair. Indoor temperature of the facility was 75. LPA was able to confirm that current residing residents had sufficient medication at this time.

The department will continue to monitor the situation with health and safety checks at this time.
Based on the observations made during this visit, there are no deficiencies cited during this visit. An exit interview was conducted and a copy of this report was provided to the facility at the end of this
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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