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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203016
Report Date: 10/02/2024
Date Signed: 10/02/2024 10:00:00 PM

Document Has Been Signed on 10/02/2024 10:00 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 LIVINGFACILITY NUMBER:
507203016
ADMINISTRATOR/
DIRECTOR:		OWENS, O GORDON, GFACILITY TYPE:
735
ADDRESS:1513 GRAPE AVETELEPHONE:
(209) 522-2089
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 16CENSUS: 15DATE:
10/02/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:House Manager Patrichia HerreraTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst, Jason Lund arrived unannounced to conduct a Plan of Correction visit. LPA Lund met with, House Manager Patrichia Herrera. House Manager Patrichia Herrera called Administrator, Greg Gordon who could not make today visit and gave permission for House Manager Patrichia Herrera to sign required paperwork. Census:15

On 9/9/2024 the facility was cited for having bed bugs. The facility 9/25/2024 through 9/27/2024 the facility was tented to exterminate the bed bugs. On 10/2/2024 LPA Lund didn’t observe any bed bugs at the facility.

No deficiencies cited on this visit, exit interview given and report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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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