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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005824
Report Date: 09/28/2021
Date Signed: 09/28/2021 04:16:41 PM

Document Has Been Signed on 09/28/2021 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LINDEN GROVE ADULT RESIDENTIALFACILITY NUMBER:
397005824
ADMINISTRATOR:CAMPBELL, MARICA Z.FACILITY TYPE:
735
ADDRESS:21373 EASTERN HEIGHTS RDTELEPHONE:
(209) 430-8869
CITY:LINDENSTATE: CAZIP CODE:
95236
CAPACITY: 6CENSUS: 5DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Ashley Strother, House ManagerTIME COMPLETED:
02:35 PM
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On 09/28/2021 at 1:05 pm, LPA T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with House Manager, Ashley Strother and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 5 ambulatory clients and 1 non-ambulatory client.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 73 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 109.2 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on July 07, 2021. Emergency Disaster Plan was last posted on 10/09/2020. Mitigation Plan observed to be complete. First aid kit was observed to be complete.

The following forms to be updated and submitted to CCLD by 10/01/2021:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan
No deficiencies cited during inspection. Exit interview conducted with House Manager and copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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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