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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002120
Report Date: 01/08/2025
Date Signed: 01/08/2025 12:19:07 PM

Document Has Been Signed on 01/08/2025 12:19 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:TRES MARIAS CARE HOME IFACILITY NUMBER:
045002120
ADMINISTRATOR/
DIRECTOR:		DEVILLA, MARIAFACILITY TYPE:
735
ADDRESS:2153 4TH STREETTELEPHONE:
(530) 532-7508
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 6CENSUS: DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Maria Devilla - licensee / administratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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01/08/2025 10:50 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with licensee/administrator Maria Devilla ( 6000858735 exp. 03/30/2025 ) and house manager Boniface Negrillo and explained the purpose of the visit.

LPA Knight and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to four (4) client rooms, common areas, one (1) bathroom, kitchen, storage areas. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate is current. During the review of staff files it was determined that 2 of 3 staff have expired first aid certificates on file.

Activities are catered to client preferences. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. Medication is locked in a cabinet.

The facility was observed to be at a comfortable temperature. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms, kitchen and storage areas were clean and in good repair .Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational. No pools/bodies of water are on premises. The facility has been conducting emergency disaster drills every 6 months and the fire drills every 3 months.

A deficiency is being cited from the California Code of Regulations and Health and Safety Code during today's visit and is documented on the attached LIC809-D. Exit Interview was conducted and appeal rights provided. A copy of the report was provided to the administrator.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/08/2025 12:19 PM - It Cannot Be Edited


Created By: Rebecca Knight On 01/08/2025 at 11:46 AM
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: TRES MARIAS CARE HOME I
FACILITY NUMBER: 045002120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 2 of 3 staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Administrator agrees to ensure that the 2 staff renew their expired first aid certificates within 2 weeks. Licensee shall submit a copy of the first aid certificates to LPA as proof of correction.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
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