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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701285
Report Date: 12/06/2023
Date Signed: 12/08/2023 04:54:50 PM

Document Has Been Signed on 12/08/2023 04:54 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: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: 1DATE:
12/06/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nicole EllTIME COMPLETED:
02:00 PM
NARRATIVE
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Unannounced Post Licensing visit made out to this facility on 12/06/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Nicole Ell. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 1 resident.
It was learned that there weren't any residents under the care of hospice at this time.
This facility does have a hospice waiver to be able to accept and retain up to (6) hospice residents at any given time.
It was learned that there weren't any residents receiving any care from a home health care agency at this time.
It was learned that there weren't any residents diagnosed with dementia at this time.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Nicole Ell. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date of 08/16/2024 with certificate # 6019506740.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinet, located in a separate room, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator at this time. This medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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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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: GATE OF BEAUTIFUL RIPON, THE
FACILITY NUMBER: 392701285
VISIT DATE: 12/06/2023
NARRATIVE
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Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually purchased on 04/23/2023 from the local hardware store and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
A review of (1) facility resident records was conducted and noted on the following LIC 858 form.
A review of (2) facility staff records was conducted and noted on the following LIC 859 form.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/08/2023 04:54 PM - It Cannot Be Edited


Created By: Charlie Yang On 12/06/2023 at 01:48 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: GATE OF BEAUTIFUL RIPON, THE
FACILITY NUMBER: 392701285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above since the resident restroom hot water temperature was measured and found to be above the allowed range of 105-120 at 136.6 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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The facility designated Administrator stated that the hot water heater will be turned down immediately. The hot water temperature will be measured daily for a length of (7) days. A statement of correction, along with a list of the temperatures taken for the past (7) days, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/08/2023 04:54 PM - It Cannot Be Edited


Created By: Charlie Yang On 12/06/2023 at 01:48 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: GATE OF BEAUTIFUL RIPON, THE
FACILITY NUMBER: 392701285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [2] personnel files did not contain the required hours of initial/ongoing training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2023
Plan of Correction
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The facility designated Administrator stated that a review of all facility personnel files will be conducted and updated to contain the required hours of initial/ongoing training. A statement of correction, along with copies of the updated initial/ongoing training hours, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
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