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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005824
Report Date: 10/23/2024
Date Signed: 10/25/2024 09:41:36 AM

Document Has Been Signed on 10/25/2024 09:41 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:LINDEN GROVE ADULT RESIDENTIALFACILITY NUMBER:
397005824
ADMINISTRATOR/
DIRECTOR:		CAMPBELL, MARICA Z.FACILITY TYPE:
735
ADDRESS:21373 EASTERN HEIGHTS RDTELEPHONE:
(209) 430-8869
CITY:LINDENSTATE: CAZIP CODE:
95236
CAPACITY: 6CENSUS: 5DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Amber Griffin ThomasTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Unannounced Annual Licensing visit made out to this facility on 10/23/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Amber Griffin Thomas, at this time. A brief interview was conducted with the facility designated Administrator at this time.
It was learned that this facility was vendorized to be able to accept and retain up to (6) Level 4I residents at any given time.
This facility was licensed to serve up to (5) Ambulatory only residents and (1) Non Ambulatory resident at any given time.
Current census was 5 residents, of which (2) of them, were out of the facility at this time at their respective day programs.
Tour of this facility was conducted. A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time.
Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time.
A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.
Medication cabinet, located in the hallway medication room, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility designated Administrator at this time. A review of the facility Medication Administration Record and dispensing log was conducted.
Medication room was observed to be locked and made inaccessible to the residents at this time.
Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LINDEN GROVE ADULT RESIDENTIAL
FACILITY NUMBER: 397005824
VISIT DATE: 10/23/2024
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and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted.
Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry area, located before the garage door exit, was toured. Cleaning supplies, detergents, and bleach were observed to be locked and made inaccessible to the residents at this time.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the garage area was conducted.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguishers were observed to be placed throughout this facility and were recently reviewed on 07/09/2024 by the local fire extinguisher company, Armor Fire Inc., and observed to be in compliance at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (5) facility resident files was conducted and noted on the following LIC 858.
A review of (5) facility staff files was conducted and noted on the following LIC 859.

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
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