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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317001368
Report Date: 09/09/2024
Date Signed: 09/09/2024 04:40:16 PM

Document Has Been Signed on 09/09/2024 04:40 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:THREE PINES ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
317001368
ADMINISTRATOR/
DIRECTOR:		SEISA, CUSTODIO A.FACILITY TYPE:
735
ADDRESS:1450 OAK RIDGE WAYTELEPHONE:
(530) 885-5181
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6CENSUS: 6DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Joel Seisa, LIcenseeTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 9/9/2024 LPA Tryon visited the facility to conduct an annual visit. LPA met with Joel Seisa, Administrator.

LPA 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 as well as 2 carbon monoxide detectors. Fire extinguishers are present and were recently 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.

LPA reviewed 2 staff files and 2 resident files. Files included required documentation. LPA interviewed 2 residents.

LPAs reviewed the CARE Tool with licensee.

The facility appears to be in substantial compliance at this time. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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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