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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
507203016
Report Date:
02/14/2024
Date Signed:
02/14/2024 07:13:56 PM
Document Has Been Signed on
02/14/2024 07:13 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:
CREATIVE ADULT LIVING
FACILITY NUMBER:
507203016
ADMINISTRATOR:
OWENS, O GORDON, G
FACILITY TYPE:
735
ADDRESS:
1513 GRAPE AVE
TELEPHONE:
(209) 522-2089
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95350
CAPACITY:
16
CENSUS:
15
DATE:
02/14/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:30 PM
MET WITH:
Administrator Gregory Owens
TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct case management visit. LPA met with Administrator Gregory Owens and explained the purpose of today’s visit.
On 1/28/2024 the facility turned in Unusual Incident/Injury Report (LIC 624) to report that room #7 had bed bugs. The facility sprayed & fumigated on 1/29/2024. The facility is continuing to treat the bed bugs.
No deficiencies were observed during the visit.
An exit interview was conducted with licensee. Exit Interview and a copy of the report left.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Jason Lund
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/14/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/14/2024
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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