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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700271
Report Date: 03/25/2022
Date Signed: 03/25/2022 09:56:36 AM

Document Has Been Signed on 03/25/2022 09:56 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ESGUERRA HOME #2FACILITY NUMBER:
342700271
ADMINISTRATOR:MARIA ESGUERRAFACILITY TYPE:
735
ADDRESS:8632 OAKBANK WAYTELEPHONE:
(916) 400-3660
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 6DATE:
03/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Maria EsguerraTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Anthony Tuck arrived at facility location unannounced on 03/25/2022. LPA was met by Administrator Maria Esguerra and explained the purpose of today’s visit regarding a recent facility action report (FAR) from ALTA Regional Center.

A brief tour of the facility was conducted. LPA reviewed a copy of the FAR that was received from Alta. Upon review of the FAR, it was learned that (2) facility staff did not complete their annual required training requirements for continuing education.

LPA learned that one staff (S1) did not pass the DSPT training class that was due on 03/08/2021 for year two. LPA learned that S1 was scheduled to complete DSPT training by 03/21/2022.

LPA learned that staff (S2) did not complete the DSPT training for year two that was due on 06/04/2020. LPA learned that S2 is scheduled to complete training on 04/30/2022.

LPA learned that the facility was given corrective action plans for deficiencies cited under CCR Title 17 section 56054 (a)(12).

LPA learned that the facility was placed on sanctions by ALTA Regional until all corrective action plans are completed in full.

LPA learned that the Administrator provided proof of classes scheduled for S1, S2 and S3 for DSPT training to Alta Regional.

Based upon review of information obtained, the following Title 22 regulation violation is being cited on the LIC 809D. Failure to correct the deficiency may result in civil penalties. Exit interview conducted with Maria Esguerra a copy of the report and appeal rights were provided upon exit.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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 2
Document Has Been Signed on 03/25/2022 09:56 AM - It Cannot Be Edited


Created By: Anthony Tuck On 03/25/2022 at 09:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ESGUERRA HOME #2
FACILITY NUMBER: 342700271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2022
Section Cited
CCR
85065(f)

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85065(f) Personnel requirements
The licensee shall ensure that all direct services to clients requiring specialized skills are performed by personnel who are licensed or certified to perform the service. This requirement was not met as evidenced by:
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Licensee is to submit a written statement of understanding of regulation cited. Licensee is to provide proof of training enrolement and training schedule for staff by POC due date.
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Based upon review of documents obtained the Licensee did not ensure that required annual staff trainings and certifications were completed by S1, and S2 by required due dates for continuing education while working at the facility. This poses an immediate health and safety risk to persons in care.
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Licensee shall submit proof of staff training certificates once completed to CCLD.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Anthony Tuck
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


LIC809 (FAS) - (06/04)
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