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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317003356
Report Date: 09/11/2023
Date Signed: 09/11/2023 11:08:50 AM

Document Has Been Signed on 09/11/2023 11:08 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:DONNIE & CECILIA PESTRANA FAMILY HOME #4FACILITY NUMBER:
317003356
ADMINISTRATOR:PESTRANA, DONNIE Q.FACILITY TYPE:
735
ADDRESS:250 WISE ROADTELEPHONE:
(916) 645-9709
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 6CENSUS: 6DATE:
09/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cecilia PestranaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Monday September 11, 2023 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed client (6) and staff (4) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPA Parks and Licensee Cecilia toured the facility together to ensure the health and safety of clients in care. The areas toured included bedrooms, kitchen, bathroom, and backyard. Water temperatures in the kitchen and bathroom were within the required range of temperature. Facility has PPE on site. In the areas toured, there were no health or safety violations observed.

No deficiencies cited. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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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