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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317001368
Report Date: 08/07/2023
Date Signed: 08/08/2023 10:20:18 AM

Document Has Been Signed on 08/08/2023 10:20 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:THREE PINES ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
317001368
ADMINISTRATOR:SEISA, CUSTODIO A.FACILITY TYPE:
735
ADDRESS:1450 OAK RIDGE WAYTELEPHONE:
(530) 885-5181
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6CENSUS: 6DATE:
08/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Chris ChuTIME COMPLETED:
04:00 PM
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On 8/7/2023 LPA Tryon and LPA Ivan Avila visited the facility to conduct an annual visit. LPAs met with Chris Chu, Administrator.

LPAs toured the house including common areas, kitchen, bedrooms, bathrooms, hallways, staff areas, yard. The facility appears to be clean and adequately furnished. Residents have appropriate furniture, bedding, etc. Smoke detectors are installed, but LPAs found that there is no carbon monoxide detector. Fire extinguishers are present and charged.
Food supplies appear appropriate to meet requirement of 2 days perishable and 7 days non-perishable. Food appears to be varied and appetizing.
Bathrooms are clean, grab bars installed, paper towels and soap available, plumbing clean and functional.

LPAs reviewed the CARE Tool with licensee.

The following deficiency are cited as per Title 22 regulations. Appeal Rights provided, exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
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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Document Has Been Signed on 08/08/2023 10:20 AM - It Cannot Be Edited


Created By: Todd Tryon On 08/07/2023 at 03:32 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: THREE PINES ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 317001368

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as there is no carbon monoxide detector installed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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The facility will obtain a carbon monoxide detector and have it installed in the facility by 8/8/2023. Receipt/proof of purchase to be submitted to LPA by POC due date of 8/8/2023.
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:Troy Ordonez
LICENSING EVALUATOR NAME:Todd Tryon
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023


LIC809 (FAS) - (06/04)
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