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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203016
Report Date: 10/22/2021
Date Signed: 10/22/2021 02:02:10 PM

Document Has Been Signed on 10/22/2021 02:02 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:CREATIVE ADULT LIVINGFACILITY NUMBER:
507203016
ADMINISTRATOR:OWENS, O GORDON, GFACILITY TYPE:
735
ADDRESS:1513 GRAPE AVETELEPHONE:
(209) 522-2089
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 16CENSUS: 11DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Gregory GordonTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the above address to conduct a required annual inspection. LPA Lund explained the reason for the visit to Administrator Gregory Gordon.

With Administrator, Gregory Gordon, LPA Lund walked the facility inside and outside of the home. Medicine cabinets and hazardous materials were locked and not assessable to residents. The exterior was in an acceptable condition. Some work could be done to neaten the appearance. There were two areas for the residents to use for leisure, one in the front of the house and one in the back. There were some lawn chairs in the backyard that ware worn out. It was recommended that they be removed and replaced. Mr. Gordon stated that he will remove and replace these chairs.

The interior of the home was found to be in a neat and clean condition. Three bathrooms were inspected and were deemed safe for residents. The home had more than the required amount of perishable food and 7-days of non-perishable. Three working carbon monoxide detectors were checked and in working order. The home smoke detectors. The two fire extinguishers were examined and have been recently inspected.

Exit interview conducted and a copy of this provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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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