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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203016
Report Date: 09/09/2024
Date Signed: 09/09/2024 12:56:16 PM

Document Has Been Signed on 09/09/2024 12:56 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:
09/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Administrator Gregory Owens TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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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. Census:

Facility Administrator Gregory Owens called LPA Lund and stated the facility is dealing with a bed bug problem and the facility will follow up with a Unusual Incident/Injury Report (LIC 624). On 9/9/2024 the facility will Pest control come out to the facility to spray & fumigate the facility and will turn in reports as such.

Deficiencies were observed during the visit.

An exit interview was conducted a copy of the report and appeals rights left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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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Document Has Been Signed on 09/09/2024 12:56 PM - It Cannot Be Edited


Created By: Jason Lund On 09/09/2024 at 12:21 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: 09/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2024
Section Cited
CCR
80087(a)(1)

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Buildings and Grounds. (a) The facility shall be clean, safe, sanitary and in good repair at all times...(1) The licensee shall take measures to keep the facility free of flies and other insects.
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The Administrator will have pest control treat the facility and report to LPA Lund progress on the bed bug situation.
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This requirement is not met as evidenced by: Based on observations, the licensee failed to ensure the facility is clean, safe, sanitary and in good repair at all times. This violation poses a potential health, and safety risk to residents in care.
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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.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Jason Lund
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
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