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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700636
Report Date: 08/23/2024
Date Signed: 08/25/2024 09:35:20 PM


Document Has Been Signed on 08/25/2024 09:35 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:GROVE, THEFACILITY NUMBER:
502700636
ADMINISTRATOR:GAITHER, NICKFACILITY TYPE:
740
ADDRESS:2801 LOU ANN DRIVETELEPHONE:
(209) 575-1950
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:74CENSUS: 34DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Mary ZunigaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a annual/required visit. LPA met with Administrator Mary Zuniga and explained the reason for the visit. Census: 34

LPA Lund and Administrator Mary Zuniga toured/inspected 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. Rooms inspected have the proper furnishings for residents in care. Smoke and carbon monoxide alert systems were hardwired and found operational. All fire extinguishers were charged (7/11/2024) and in compliance.

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. Adequate supply of linens is stored in laundry room. Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen. LPA Lund reviewed 3 staff & 4 residents files and were in compliance.

No deficiencies were cited during the visit. An exit interview and report left.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024
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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