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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701422
Report Date: 11/27/2024
Date Signed: 11/27/2024 11:00:27 AM

Document Has Been Signed on 11/27/2024 11:00 AM - 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:SAN GABRIEL RESIDENCEFACILITY NUMBER:
502701422
ADMINISTRATOR/
DIRECTOR:		SANDHU, JEEVANJOATFACILITY TYPE:
735
ADDRESS:1801 SAN GABRIEL DR.TELEPHONE:
(209) 531-6694
CITY:HUGHSONSTATE: CAZIP CODE:
95326
CAPACITY: 4CENSUS: 0DATE:
11/27/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Jeevanjoat Sandhu, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Renee Campbell conducted an announced pre-licensing visit to this facility on 11/27/2024 and met with Jeevanjoat Sandhu, Licensee who will also be the Administrator for the facility ( #7015714735).  It was learned that this facility will be licensed as an ARF to serve up to 4 ambulatory clients . There were no clients present during today's pre-licensing visit. The facility is a single floor building with 4 bedrooms and 2 bathrooms. Bathrooms were not reflected in the Facility Sketch on display. A tour of the facility was conducted.  The facility was well lit and free of odor and was sanitary. Per the Administrator, the phone had been working for the past four months but was now not working.

Dining area, living area, and all other areas intended for resident use were toured and observed with minimal furniture. An emergency disaster plan, facility sketch, See Something, Say Something and Personal Rights notice were observed on the dining room table. All notices were printed on legal size paper. Fire extinguisher was in place in the dining room area and fully charged with an inspection date of 10/25/2024.  The smoke and carbon monoxide alarms were tested successfully and were found be functional. Kitchen area was toured.  Cabinets and drawers were opened and reviewed by this LPA along with the Applicant. The medication cabinet, first aid kit and a thermometer were located in a secured cabinet in the kitchen.  A first aid kit was observed to be present but did not contain scissors.

A tour of the resident bedrooms were conducted.  Furnishings and furniture intended for use by the clients were observed.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2024
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 2
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: SAN GABRIEL RESIDENCE
FACILITY NUMBER: 502701422
VISIT DATE: 11/27/2024
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Per the licensee, the twin mattresses were still boxed and would need to be returned and replaced with Extra Long Twin mattresses. The one full mattress needed had not arrived. All rooms had the required closet, chair, night stand and night lamp. Drawers were not present. 

In the bathroom, hot water temperatures were taken and measured at 120 degrees Fahrenheit which is within the allowed range of 105-120 degrees. The hot was temperature was measured at 125 degrees Fahrenheit. A tour of the exterior grounds was conducted.  A review of the facility perimeter fence, side gates, and walkways were observed. The pathways will need to be swept and yard debris removed from all pathways. There was an enclosed patio area with a sink and stove that will be used as an additional visitor/seating area. At this time, there was no furniture in the patio

Prior to licensure, the following shall be corrected and verification sent to LPA Renee Campbell at CCLASCPSacramentoRO@dss.ca.gov .
  • Scissors and full size tweezers for the first aid kit
  • Poster Size 'See Something, Say Something' and Ombudsman signage
  • Administrator Certificate displayed
  • Mattresses on all beds
  • Working Phone
  • Drawers for resident bedrooms.
  • Updated Facility Sketch for display with bathrooms.
  • Lower the hot was temperature for the water in the kitchen.

LPA Campbell observed that facility is not ready to be licensed. Exit interview conducted and a copy of the report was left with the licensee.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2024
LIC809 (FAS) - (06/04)
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