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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005824
Report Date: 10/15/2022
Date Signed: 10/17/2022 11:35:46 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/17/2022 11:35 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
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:
10/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Marco AutriaTIME COMPLETED:
01:31 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 116.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA 4 reviewed resident files. LPA was unable to reviewed resident or staff files they were locked and the key was not at the facility. The licensee will bring the files, four staff (4) files to the office located at 2525 Natomas Park Suite 270, Sacramento, CA 95833 on 10/19/2022 at 1:30pm. During the inspection LPA observed an outside vendor working with R1. The behavior consultant is contracted by the family and written into his IPP. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Advisory given.

Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2022
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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