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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700581
Report Date: 05/16/2024
Date Signed: 05/16/2024 12:41:01 PM


Document Has Been Signed on 05/16/2024 12:41 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 4DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sarena Arias TIME COMPLETED:
01:00 PM
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On 05/16/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Facility Designated Representative (FDR), Sarena Arias and explained the purpose of the visit.
This facility is licensed to served 6 residents, all of whom may be non-ambulatory. This facility also has a dementia plan on file and has a current hospice waiver for 6.
Current census was 4. 3 out 4 residents were out at of the facility at this time.

A brief interview with FDR Arias was conducted.
LPA reviewed 4 resident files.LPA reviewed 3 staff files. 3 out of 3 staff files were complete and up to date. Facility Designated Administrator currently holds an active and current administrator certificate #6019506740 and expires on 08/16/2024.
A tour of the facility was conducted.
The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annual inspected by Jorgenson Fire Co and is valid until 09/19/2024.
The kitchen area was toured. LPA observed a sufficient supply of 7 day non-perishable and 2-day perishable food supply in the pantry and refrigerator.
LPA observed a locked centralized stored medication cabinet located in the laundry room. Along with the FDR, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time

A tour of the bathroom was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
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: GATE OF BEAUTIFUL II, THE
FACILITY NUMBER: 502700581
VISIT DATE: 05/16/2024
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A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.

Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Additional perishable food supplies were identified.

The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Liability Insurance

-Surety Bond

A technical violation is being provided today for 87458(a). LPA discussed that physicians report must be conducted on a yearly basis.

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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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