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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804173
Report Date: 07/29/2026
Date Signed: 07/29/2026 01:43:21 PM

Document Has Been Signed on 07/29/2026 01:43 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:GRAND RIVER VILLAFACILITY NUMBER:
576804173
ADMINISTRATOR/
DIRECTOR:		LUCELI SOTO-LUISFACILITY TYPE:
740
ADDRESS:509 MICHIGAN BLVDTELEPHONE:
(916) 373-1591
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY: 43CENSUS: 21DATE:
07/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:11 AM
MET WITH:Allison Lopez, Regional Nurse and Robert Godfrey, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:42 PM
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On 07/29/2026, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced and was greeted by Regional Nurse, Allison Lopez. Administrator Robert Godfrey arrived shortly. The purpose of the visit is an Annual Inspection. There are currently 21 residents residing at the facility. There were 2 caregivers and one med tech at the time of inspection, as well as the Regional Nurse, the Administrator, Dietary Lead and Regional Maintenance Director.

LPA inspected the facility's kitchen and found it clean and well organized, with an ample supply of perishable and non-perishable foods, as required per Title 22. There were also emergency supplies stored. LPA discussed an updated menu. Kitchen knives are locked in storage closet in kitchen when not in use. Residents' rooms were clean and furnished as per regulation. Bathrooms had soap and paper towels. Water temperature measured between 105 and 114 degrees F, which is within regulation. Common areas including the dining room, activities room and the Great Room were all clean and well organized. Medications were locked and stored in general office and on the medication cart. Fire extinguishers throughout the building were fully charged. The last fire drill took place on 07/28/2026 and the last fire inspection was on 06/09/2025. Carestaff do several activities over the course of the day including chair exercise, BINGO, bible study, arts and crafts. The outdoor areas were free from debris and all windows had screens. The outdoor courtyard provides seating for residents and visitors, but relies on shade trees to provide shade to the area.

Three (3) resident files and five (5) staff files were reviewed and found to be complete. Facility is switching over to electronic file system. LPA requested that Administrator review training records and transcripts and organize.

LPA requested an updated LIC500, proof of Liability Insurance, updated Emergency Disaster Plan, updated Infection Control Plan.

No deficiencies found at the time of inspection. No citations.
Exit interview conducted with Administrator Robert Godfrey.
Kimberley Mota
Jill Nakagawa
DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2026
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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