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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001734
Report Date: 04/16/2025
Date Signed: 04/16/2025 03:29:32 PM

Document Has Been Signed on 04/16/2025 03:29 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/
DIRECTOR:		MOKTAN, BIRBAHADURFACILITY TYPE:
740
ADDRESS:107 PINECREST AVENUETELEPHONE:
(530) 885-8203
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
04/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Birbahadur "Danny" MoktanTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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LPA Hiratsuka, conducted this unannounced annual visit. LPA toured the facility with Danny Moktan. There are five residents in care at this time. There are three private and one shared resident room on the left side of the main entrance to this facility. There is a licensee quarters located behind the utility room next to the kitchen. There is also a private resident room next to the kitchen that has an exit to a patio. There is a caregiver's quarters connected to the living room. There is one full common bathroom and one private bathroom in the shared room. The resident room in the front of the facility to the right of the entrance and the room between that one and the shared room have a door connecting the two rooms on the shared wall. The middle room has an exit to the outside. Precautions are taken for privacy when they are occupied; however, the connecting door cannot be blocked on either side per fire code because in case of emergency, the middle room is the exit for both rooms. The shared room has an exit to the outside. There are two patio areas that the facility has exits to. There is a wood deck in the back patio that has a ramp leading to the side of the facility. There are sheds in the backyard. The second patio is next to the dining room and private client room. Kitchen was inspected. There is a locked cabinet under the sink that stores soaps for the dishes and dishwasher. There is an ample perishable supply and the nonperishable supply is adequate. Medications are stored in a locked cabinet in the kitchen.

Staff and resident records were reviewed during visit.
Several topics were discussed during this visit.


No citations issued during this visit.
Troy OrdonezTELEPHONE: (916) 263-4700
Kerry HiratsukaTELEPHONE: (916) 591-0210
DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2025
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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