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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001734
Report Date: 04/05/2023
Date Signed: 04/07/2023 10:31:31 AM


Document Has Been Signed on 04/07/2023 10:31 AM - 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:PINECREST RETIREMENT HOMEFACILITY NUMBER:
315001734
ADMINISTRATOR:MOKTAN, BIRBAHADURFACILITY TYPE:
740
ADDRESS:107 PINECREST AVENUETELEPHONE:
(530) 885-8203
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 3DATE:
04/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Birbahadur Moktan (Danny)TIME COMPLETED:
01:00 PM
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On 4/5/2023 LPA Tryon visited the facility to do an annual visit. LPA met with licensee Danny Moktan.
LPA used the CARE Tool to evaluate the facility.
LPA reviewed the CARE Tool with Mr. Moktan.
LPA reviewed staff and resident files, toured the facility including bedrooms, bathrooms, kitchen, fool storage and supplies, common areas, outside areas/patio. The facility has smoke detectors and carbon monoxide detectors. Fireplace/insert has a sturdy screen around it. Bathroom and kitchen fixtures are functional. Non-skid surface in shower, grab bars installed. Food supply meets requirement of 2 days perishable and 7 days non-perishable.
The facility is clean and in good repair overall.
Appropriate postings present.
Administrator certificate current.
Facility carries liability insurance. Administrator will send a copy of the current policy to CCL,
Medications are centrally stored and locked in a kitchen cabinet.

The facility appears to be in substantial compliance at this time. No deficiencies cited at this visit.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
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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