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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700581
Report Date: 05/21/2021
Date Signed: 05/21/2021 02:48:39 PM

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:GATE OF BEAUTIFUL II, THEFACILITY NUMBER:
502700581
ADMINISTRATOR:ELL, NICOLEFACILITY TYPE:
740
ADDRESS:3300 SHARON AVETELEPHONE:
(209) 526-2425
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 3DATE:
05/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sharon MartinTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia and (LPA) Albert Johnson conducted an unannounced annual / Infection Control visit on this date. LPAs met with Administrator, Sharon Martin at The Gate of the Beautiful II.

LPAs and administrator inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, medications rooms and dining room areas. LPAs observed sufficient seven days non-perishable and two days perishable food supplies in the main kitchen. Hot water temperature was measured in residents bathroom with the Administrator and measured at 108 degrees which is in the required range of 105 to 120 degrees. LPAs observed there was no Carbon Monoxide in facility. LPAs observed oxygen in the garage with no visible signs. Administrator stated resident keeps a tank in his room. LPAs observed no visible signs in residents room. Administrator did not have the Fire Drill log on site. LPAs could not verify when the last FireDrill was conducted,.

LPAs reviewed 5 staff files and 3 resident files. While reviewing resident files, LPAs observed: R1 missing TB test and R2 Pre-appraisal signed but incomplete, 602, and Physicians Report.

Cont 809-C >>>>>>>>>>>>>>>>>>>>
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GATE OF BEAUTIFUL II, THE
FACILITY NUMBER: 502700581
VISIT DATE: 05/21/2021
NARRATIVE
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Prior to visit, LPA Garcia completed a File Review. LPAs observed License Fee has not been received.

LPAs reviewed resident and staff files. LPAs requested:

1. LIC 309 Administrative Organization
2. LIC 500 Personnel Report

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with Sharon Martin and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GATE OF BEAUTIFUL II, THE
FACILITY NUMBER: 502700581
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2021
Section Cited

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80020(a) - Fire Clearance
All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:

Liability Insurance
Theft and Loss Policy Procedures

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with Remy Raqueno and a copy of report given at the conclusion of the visit.
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Based on LPA observation the Licensee did not have a Carbon Monoxide on site.
This poses an immediate health and safety risk to clients in care.
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Type B
05/21/2021
Section Cited

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Disaster and Mass Casualty Plan - Disaster drills shall be conducted at least every six months. The drills shall be documented and the documentation maintained in the facility for at least one year.
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 This requirement was not met as evidenced by records reviewed, facility did not have record of fire Drills log on site. This poses a potential safety risk to the residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GATE OF BEAUTIFUL II, THE
FACILITY NUMBER: 502700581
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2021
Section Cited

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87618 (b)(3)(B) Oxygen Administration - Gas and Liquid - Oxygen in Use signs shall be posted in appropriate areas.
This regulation was not met
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Based on observation and interview the Administrator did not post oxygen in use signs of the resident(s) rooms that had oxygen.
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Type B
05/21/2021
Section Cited

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80036. Licensing Fees(b)(1) In addition to fees set forth in subdivision (a), the department shall charge the following fees:
(F) A late fee that represents an additional 50 percent of the established annual fee when any licensee fails to pay the annual licensing fee on or before the due date as indicated by postmark on the payment.

This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above in paying annual fees timely, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GATE OF BEAUTIFUL II, THE
FACILITY NUMBER: 502700581
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2021
Section Cited

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87506(b)(1-17) (A-F)
Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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This requirement is not met as evidenced by: Based on review of resident files and observation of documentation, the licensee did not ensure resident records are competed signed and dated as required by Title 22 Regulations. This violation poses a potential health, and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5