<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317003356
Report Date: 09/10/2024
Date Signed: 09/10/2024 11:02:28 AM

Document Has Been Signed on 09/10/2024 11:02 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/
DIRECTOR:		PESTRANA, DONNIE Q.FACILITY TYPE:
735
ADDRESS:250 WISE ROADTELEPHONE:
(916) 645-9709
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 6CENSUS: 6DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Cecilia PestranaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday September 10, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed client (6) and staff (3) files. All client files contained the required paperwork. All staff files contained the required paperwork and training.

LPA Parks and Administrator Cecilia toured the facility together to ensure the health and safety of clients in care. The areas toured included bedrooms (3), kitchen, bathroom, laundry room, front and backyard. All chemicals and toxins were kept locked and inaccessible to clients. Facility had one fire extinguisher with a current inspection tag. First aid kit was fully stocked. Facility was current with fire drills. In the areas toured, there were no health or safety violations observed.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1