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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701285
Report Date: 05/30/2023
Date Signed: 05/30/2023 12:55:48 PM

Document Has Been Signed on 05/30/2023 12:55 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GATE OF BEAUTIFUL RIPON, THEFACILITY NUMBER:
392701285
ADMINISTRATOR:ELL, NICOLEFACILITY TYPE:
740
ADDRESS:836 SUNRISE AVETELEPHONE:
(209) 614-5171
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY: 6CENSUS: 0DATE:
05/30/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nicole EllTIME COMPLETED:
01:00 PM
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On 5/30/23 at approximately 10am Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility announced to conduct a pre-licensing visit. LPAs Jensen met with Licensee Nicole Ell and explained the pre-licensing process.

LPAs Jensen and Fain toured the grounds and physical plant. The grounds were observed to be clear of debris and all paths were unobstructed. LPA Jensen observed patio furniture with shaded areas for residents to enjoy outdoor activities. The physical plant has 4 resident bedrooms and 1 owner quarters. The interior of the facility was observed to be sanitary, adequately furnished and adequately lit. The bathrooms are equipped with grab bars and non-slip flooring. The facility maintains an adequate supply of linens and hygiene products. The bedrooms contained a night stand, lamp, dresser and chair. The mattresses were observed to have mattress covers. The waste cans were observed to have tight fitting lids. The facility has a locked storage area for medications, toxins and knives. All appliances appeared to be in good working order. There are night lights available in the hall way . The first aid kit is complete with scissors, tweezers, thermometer, manual and various wound dressings. The Emergency Disaster plan was reviewed and determined to be in compliance. The fire extinguishers were purchased in April of 2023 and are in compliance. The carbon monoxide detectors and smoke detectors were determined to be in good working order. All required signs including resident rights, resident council, and "See Something, Say Something" were prominently posted for viewing by residents. The facility maintains activities for resident engagement. The Pre-Licensing Inspection Tool was utilized during the course of this visit.

The facility was determined to be in substantial compliance with the Health and Safety Code and the California Code of Regulations. The facility has passed the pre-licensing inspection. Component III was conducted.

An exit interview was conducted and a copy of this report was provided to Licensee Nicole Ell.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2023
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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