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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203016
Report Date: 10/17/2024
Date Signed: 10/18/2024 08:24:26 AM

Document Has Been Signed on 10/18/2024 08:24 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: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:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator Gregory Gordon TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a one year required/annual inspection. LPA Lund met with Administrator Gregory Gordon and explained the reason for the visit. Census:15

LPA Lund & Administrator Gregory Gordon toured/inspected 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. There were two areas for the residents to use for leisure, one in the front of the house and one in the back. 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, and two fire extinguishers (8/21/2024) were in compliance at this time. LPA Lund reviewed two staff & four clients files and were in compliance at this time.

Per the California Code of Regulations, Title 22 no deficiencies were observed or cited.
Exit interview conducted and a copy of this provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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