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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700581
Report Date: 04/27/2022
Date Signed: 04/27/2022 12:29:54 PM


Document Has Been Signed on 04/27/2022 12:29 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:GATE OF BEAUTIFUL II, THEFACILITY NUMBER:
502700581
ADMINISTRATOR:NICOLE ELLFACILITY TYPE:
740
ADDRESS:3300 SHARON AVETELEPHONE:
(209) 526-2425
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 5DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Nicole Ell - AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Required Annual Inspection Visit.. LPA met with Administrator and explained the purpose of visit. Administrator Certificate #6019506740 Expires 08/16/2022

LPA and administrator inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, medications rooms and dining room areas. LPA observed sufficient seven days non-perishable and two days perishable food supplies in the main kitchen. Hot water temperature was measured in kitchen sink at 113.5 F degrees which is in the required range of 105 to 120 degrees. LPA observed Carbon Monoxide in facility. Fire Extinguishers expire 09/01/2022. LPA observed oxygen signs for resident and a tank is kept in his room. Last Fire Drill was conducted 2/8/2022.

LPA reviewed (4) staff files. All staff is fingerprint cleared and associated to the facility and staff currently have First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. LPA reviewed 4 resident files which are complete. LPA reviewed 3 of resident medication files, which files were complete. Residents' medications are stored in a locked cabinet.
LPA received the following documents for annual inspection:
LIC 308 Designation of Facility Responsibility
LIC 500 Personnel Report
LIC 610 E - Emergency Disaster Plan
Copy Administrator Certificate
Current Liability Insurance - 06/25/2022
Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies are being cited today. Exit interview held with Administrator and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
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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