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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317003837
Report Date: 04/24/2024
Date Signed: 04/24/2024 04:43:53 PM

Document Has Been Signed on 04/24/2024 04:43 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:DONNIE & CECILIA PESTRANA FAMILY HOME #6FACILITY NUMBER:
317003837
ADMINISTRATOR/
DIRECTOR:
PESTRANA, DONNIEFACILITY TYPE:
735
ADDRESS:996 KEITH DRTELEPHONE:
(916) 781-7742
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 6DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Michael LigpitTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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) Kevin Mknelly arrived at the facility unannounced on 4/24/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator designee arrived to assist. LPA advised that if licensee wishes, to update administrator.

LPA and administrator toured the interior and exterior of the facility to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, three (3) resident bedrooms, two (2) bathrooms, kitchen, and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of one week and perishable foods for a minimum of two days. Toxic and cleaning supplies locked and is inaccessible to clients in care. The hot water temperature was measured within range. First aid kit was completed. Meds removed from kits. LPA observed fire extinguisher/carbon monoxide alarms to be in working order and the fire extinguisher service is up to date. Some advisories discussed.

LPA reviewed 6 resident files. Files are complete and well organized. Some advisories discussed

LPA reviewed 2 staff files. Files are complete.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted with licensee and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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 6