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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002120
Report Date: 07/16/2024
Date Signed: 07/16/2024 01:10:47 PM

Document Has Been Signed on 07/16/2024 01:10 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: 4DATE:
07/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Maria Devilla - administratorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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07/16/2024 12:15 PM LIcensing Program Analyst (LPA) Rebecca Knight arrived unannounced to conduct a case management visit related to deficiencies cited by Far Northern Regional Center (FNRC) on 07/10/2024. LPA met with administrator Maria Devilla and Bonie Megrillo and explained the purpose of the visit.

LPA reviewed the Corrective Action Plan (CAP) provided to the Department by FNRC on 07/11/2024, describing the specific deficiencies found. The deficiencies were observed as follows:

On 07/10/2024 during an inspection by FNRC staff deficiencies were issued due to spoiled food that was found in the pantry with cockroaches actively present, and rodent feces was also found in pantry. Rodent feces and signs of nesting found in client's dresser drawers. Multiple gaps were found between the baseboard and wall in two client bedrooms which could potentially allow rodents to enter the facility.

On 07/16/2024 LPA observed pantry had been cleared of all old food, cleaned and sanitized. Drawers in client rooms have been cleaned and sanitized. Two client rooms had recent repairs to gaps in baseboards to prevent rodents from entering the home.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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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Document Has Been Signed on 07/16/2024 01:10 PM - It Cannot Be Edited


Created By: Rebecca Knight On 07/16/2024 at 12:39 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: TRES MARIAS CARE HOME I
FACILITY NUMBER: 045002120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2024
Section Cited
CCR
80087(a)

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80087(a) Buildings and Grounds - (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:
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Licensee agrees to obtain a pest control inspection by a licensed professional and complete any treatment recommendations made by that licensed professional. In addition, licensee agrees to complete the repair of gaps in floorboards that allow rodents to get in the facility. Licensee will also remove and destroy all food in pantry. Licensee shall hire professional cleaning service to clean and sanitize the entire home.
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Based on the evidence that was obtained it was determined that the licensee failed to keep the facility free of rodents and cockroaches which poses a potential health and safety risk to residents in care.
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LPA toured facility and conformed that all requirements have been met, reviewed invoices for services rendered by pest control and cleaning service. POC complete.

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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: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: TRES MARIAS CARE HOME I
FACILITY NUMBER: 045002120
VISIT DATE: 07/16/2024
NARRATIVE
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LPA reviewed the following invoices: Gecko Pest Control completed service to the home on 07/11/2024, they will be coming for follow up service in two weeks and moving forward will service the home monthly. Clean Masters cleaned and sanitized the home on 07/12/2024 and will be coming into the home each month moving forward to perform cleaning and sanitization services. LPA reviewed invoices from a local hotel showing that all clients and staff had stayed in the hotel for 5 nights while all services were completed.

Based on evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D.



An exit interview was conducted. Copy of report and appeal rights were provided to administrator Maria Devilla.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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