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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 030317773
Report Date: 09/14/2026
Date Signed: 09/14/2026 02:41:23 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/14/2026 02:41 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:AMADOR RESIDENTIAL CARE FACILITYFACILITY NUMBER:
030317773
ADMINISTRATOR/
DIRECTOR:		KARLY STURGEONFACILITY TYPE:
740
ADDRESS:155 PLACER DRIVETELEPHONE:
(209) 223-4444
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 49CENSUS: 29DATE:
09/14/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Karly Sturgeon, Administrator, Executive Director TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 09/14/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct the annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPA met with Executive Director (ED) Karly Sturgeon and a brief meeting followed.

Sturgeon has been the Designated Facility / Executive Director (ED) for 3 years. They stated that they will be taking on a new role as Senior Executive Director in their corporate offices in the near future once the new ED for this facility has completed their RCFE certification program. LPA offered assistance in expediting the process and explained the documentation required for a change of administrator.

The LPA and the ED then toured the facility. The facility was conducting a theme week for all to enjoy and today was pajama day. Most staff were participating and dressed accordingly. LPA observed residents in the main common area enjoying donuts and watching the movie, "The Notebook."

This LPA inspected 4 resident rooms in the main part of the facility (24, 27, 29, and 40) and 3 others in memory care (2, 9, and 10). All had the required lighting, furniture, and furnishings to be in compliance at the time of this inspection. Restrooms all had the required grab bars, and non-skid surfaces in the showers.
LPA measured the hot water in the bathroom of room 27 and found it to be 118.8 degrees Fahrenheit and in compliance at the time of this inspection.

The tour proceeded into the kitchen. LPA observed a 7-day nonperishable and 2-day perishable food supply. The facility has not has a Dietary Supervisor for the past 3 months but they do have a contract with a
Lisa Rios
Kimberly Viarella
DATE: 09/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2026
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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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: AMADOR RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 030317773
VISIT DATE: 09/14/2026
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dietary consultant that provides menus and planning guides. The 7 fire extinguishers stationed throughout the building were last inspected on 11/18/2025 by Sierra Foothill Fire Extinguisher Service and were in compliance at the time of this inspection. LPA inspected the freezers, refrigerator, and pantry areas. A selection of items were chosen from each and none were stored past their expiration dates. LPA reviewed proper food storage practices to ensure future compliance.

LPA and ED next inspected the Medication Room. LPA observed that all of the medications to be destroyed were in a locked med cart. LPA inspected the current resident medications in a second med cart to ensure that none had expired. LPA reviewed PRN administration as well. All were in compliance at the time of this inspection.

LPA conducted a file review of 3 out 6 selected staff files. All were complete and in compliance at the time of this inspection. A review of 3 out of 6 selected resident files was completed. All required documents were present and the files were complete at the time of this inspection.

A tour of the exterior of the facility was also conducted. All windows, screens, and gutters were in good repair at the time of this inspection. The facility was completely fenced in with no bodies of water present. There were areas in both the front and rear of the facility with shade and furniture for residents to enjoy. Today this LPA observed 2 families interacting during visits with their loved ones in the one of shaded areas. During this visit, this LPA also observed therapy dogs that were brought in for residents to enjoy.

According to the California Code of Regulations, Title 22, technical assistance was provided regarding food storage but no deficiencies were cited during today's visit. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Sturgeon.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2026
LIC809 (FAS) - (06/04)
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