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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317003519
Report Date: 03/06/2024
Date Signed: 03/06/2024 02:21:37 PM

Document Has Been Signed on 03/06/2024 02:21 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:DONNIE & CECILIA PESTRANA FAMILY HOME #5FACILITY NUMBER:
317003519
ADMINISTRATOR:PALMER, EMILYFACILITY TYPE:
735
ADDRESS:1514 LATHWELL WAYTELEPHONE:
(916) 773-0844
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 5DATE:
03/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Emily Palmer, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Emily Palmer during today's inspection.

LPA reviewed facility fire clearance and facility sketch with Administrator. Administrator agrees to submit an update facility sketch into CCL. LPA reviewed client P&I money, and documentation.

Administrator agrees to submit to LPA P&I documentation and bank statements by 3/25/24. In addition Administrator will submit an updated facility sketch and LIC200 by 3/25/24.

No deficiencies cited during today's inspection.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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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