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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001734
Report Date: 03/14/2024
Date Signed: 03/14/2024 03:48:06 PM


Document Has Been Signed on 03/14/2024 03:48 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:PINECREST RETIREMENT HOMEFACILITY NUMBER:
315001734
ADMINISTRATOR:MOKTAN, BIRBAHADURFACILITY TYPE:
740
ADDRESS:107 PINECREST AVENUETELEPHONE:
(530) 885-8203
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 2DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Birbahadur (Danny) Moktan, LicenseeTIME COMPLETED:
04:00 PM
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On 3/14/2024 LPA Tryon visited the facility to do an annual visit. LPA met with Danny Moktan.
The facility currently has 2 residents. LPA toured the facility including common areas, kitchen, bedrooms, hallways, laundry, patio, yard, bathrooms.
The facility appears to be clean and in good condition. Food supplies appear adequate to meet the requirement of 2 days perishable and 7 days non-perishable. Medications are centrally stored and locked. Cleaners and other potentially hazardous items are secured. No hazards were noted. Smoke detectors and carbon monoxide detector installed and functioning, fire extinguisher present and charged. Furniture, furnishings and plumbing in good and functional condition.
There is a large patio out the back door with various chairs and tables for residents to spend time outside, all in good condition.

LPA reviewed the CARE Tool with Administrator.
LPA reviewed staff training, and reviewed 2 of 2 resident files.
LPA was not able to interview a resident, as one resident was out with family and the other resident only communicates via sign language.

At this time the facility appears to be in substantial compliance with the regulations.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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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