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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203016
Report Date: 11/20/2025
Date Signed: 12/19/2025 02:44:39 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/19/2025 02:44 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: 14DATE:
11/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Gregory Gordon, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 11/20/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to conduct a inspection. LPA Campbell met with Gregory Gordon, Administrator and explained the purpose of the visit.
Upon entry to the facility, LPA Campbell observed a TV room with seating for residents. A See Something Say Something poster was in the room and easily viewable for residents and visitors.

Staff guided LPA Campbell to the kitchen to work. The Ombudsman poster was observed in the kitchen with contact information. The temperature at the kitchen sink was 116 degrees Fahrenheit. The freezer temperature was -01 degrees Fahrenheit (F). The refrigerator temperature was 36 degrees F. Storage for resident medication is kept in the kitchen and kept locked and inaccessible to residents. The laundry room is also in the kitchen. Residents bring the clothes to be washed, and staff handle adding the detergent, which is kept in a locked cabinet above the washer.

The facility is a single story building licensed to serve 16 residents who are ages 18 to 59. Those who reside in the facility will be ambulatory only. Currently, there are 14 people residents in the facility. In the two bedrooms observed in the facility, both contained a bed, chest, lamp and night stand as well as a closet. Beds were made with blankets, sheets and pillows. Floors were free of obstacles.

Per the administrator, there are 4 staff working in the facility in all. There is 1 staff member who resides in the facility. LPA Campbell observed the staff living area which included a bedroom and separate bathroom and office. During a tour of the facility, LPA Campbell observed a thermostat set at 68 degrees F. The 4 bathrooms in the facility were found to be clean and free of odor. The fire extinguisher was last inspected 10/06/2025 and was fully charged.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: CREATIVE ADULT LIVING
FACILITY NUMBER: 507203016
VISIT DATE: 11/20/2025
NARRATIVE
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The outdoor space consisted of a smoking area and seating. There are also two locked sheds that contain equipment and excess non-perishable food items.

During the staff file review, when LPA Campbell could not find the start date for staff. LPA Campbell asked Administrator Gordon for the staff tax forms to view the start date. Administrator Gordon then stated that they "paid staff in cash" so there were no tax forms. LPA Campbell informed the administrator that as a business, the facility was required to report staff earnings to the IRS. Upon further review of the administrators file, LPA Campbell also observed a Certificate of Completion from UC Davis for "Labor Law: All You Need to Know and What You Must Pay" and the class "Understanding and Maintaining Regulatory Compliance" on July 6, 2019. The Assistant Administrator also took a class called Business Operations. Therefore, both administrators should have been aware of the business requirements for the facility.

LPA Campbell consulted with the Licensee/Administrator and reminded him that it was also his responsibility to manage unemployment insurance and workers compensation.

Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed or cited and noted on LIC 809D. Note that failure to correct any deficiencies will result in additional civil  penalties.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2025 02:44 PM - It Cannot Be Edited


Created By: Renee Campbell On 11/20/2025 at 12:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CREATIVE ADULT LIVING
FACILITY NUMBER: 507203016

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/25/2025
Section Cited
CCR
80064(a)(3-4)

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Administrator - .. Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. (4) Ability to maintain ... financial and other records.
This requirement was not met based on:
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Licensee will providei information from the IRS regarding the consequenes of not reporting wages. The licensee will identify the form current and future staff must fill out by the POC due date and submit completed forms for current staff to LPA Campbell via email by the POC due date.
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Based on interviews and record reviews, the licensee admitted that staff were paid in cash and thus did not comply with applicable law and regulation and that they did not ensure wages were reported to the IRS which poses a potential Health, Safety and Personal Rights risk to persons in Care.
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Licensee will also identify the process they will undertake to sign up for unemployment insurance and workers compensation as well or proof of same.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Renee Campbell
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
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