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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701285
Report Date: 01/03/2024
Date Signed: 01/08/2024 04:17:34 PM

Document Has Been Signed on 01/08/2024 04:17 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:
01/03/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Serena PhylombiaTIME COMPLETED:
02:30 PM
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Unannounced Plan of Correction visit made out to this facility on 01/03/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff person Serena Phylombia. A brief interview was conducted with the facility staff person at this time.
This LPA requested that the facility staff person go ahead and contact the facility designated Administrator, Nicole Ell, to inform her that CCL was present at this time.
Current census was 1 resident.
The purpose of this visit was to verify the plan of correction that was required to be completed for deficiencies that were previously cited on a prior visit conducted on 12/06/2023.

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.

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.

The deficiencies were corrected and brought into compliance at this time. Clearance letters were printed and a copy was given to the facility staff person at this time.

There were no further deficiencies observed or cited during today's plan of correction visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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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