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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700636
Report Date: 07/26/2021
Date Signed: 07/26/2021 12:29:10 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:GROVE, THEFACILITY NUMBER:
502700636
ADMINISTRATOR:GAITHER, NICKFACILITY TYPE:
740
ADDRESS:2801 LOU ANN DRIVETELEPHONE:
(209) 575-1950
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:74CENSUS: 24DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Chris GaitherTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPAs) Jason Lund and Sarah Hunt arrived unannounced to conduct a one year required visit. LPAs met with Facility Administrator Chris Gaither and explained the reason for the visit.

LPAs Lund, Sarah Hunt and Administrator Chris Gaither walked the facility. The facility is a single-story building with 43 resident bedrooms, common area, activity room, dining area and kitchen. The facility has delayed egress perimeter. All bedrooms will have furnishings for 74 residents. Smoke and carbon monoxide alert systems were hardwired and found operational. All extinguishers were charged and mounted. The kitchen was observed to be clean and operational. Washer and dryer are located in the laundry room and were clean and noted to be operational. Toxins are locked and stored in the utility closet.

No deficiencies were cited during the visit. An exit interview was conducted, with Administrator Chris Gaither and a copy of this report was provided at the time of visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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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