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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700328
Report Date: 04/15/2024
Date Signed: 04/15/2024 04:21:35 PM

Document Has Been Signed on 04/15/2024 04:21 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:C G ESTEPA CARE HOMEFACILITY NUMBER:
342700328
ADMINISTRATOR/
DIRECTOR:
ESTEPA, GEMMA CFACILITY TYPE:
735
ADDRESS:10801 GLENHAVEN WAYTELEPHONE:
(916) 670-0180
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 4CENSUS: 4DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Gemma Estepa TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 4/15/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct an annual inspection. LPA identified herself upon arrival and asked to speak with the Designated Facility Administrator (DFA). LPA met with Gemma Estepa and a brief interview followed.

DFA Certificate #6027135735 expires 7/21/25.

LPA began inspection in the kitchen. All knives and sharps were in a locked drawer and inaccessible to clients in care. LPA inspected the pantry and refrigerator. LPA observed 2 days of perishable and 7 days of non-perishable food. LPA observed the Fire Extinguisher was last inspected on 08/03/23 by Jorgenson Co.

LPA observed all 4 resident rooms as well as the dining room and living room were equipped with the required furniture, furnishings and sufficient lighting. The two bathrooms were equipped with soap and paper towels. LPA measured the hot water and temperature measured at 114 degrees Fahrenheit which met the 105-120 degree Fahrenheit regulation.

First aid kit was checked and was complete. LPA observed centrally stored medications were secured from residents in an locked filing cabinet in the kitchen. Storage, administration, and dosing were reviewed by LPA along with PRN procedures.

LPA toured the exterior of the facility. There were no bodies of water present and the yard was completely fenced in. There was a shed that the staff opened for the LPA. It contained additional supplies and holiday decorations. There was a large covered patio area with furniture for residents to enjoy. All screens and gutters were in good repair.

LPA performed a records review. All resident and staff files reviewed were complete and in compliance.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: C G ESTEPA CARE HOME
FACILITY NUMBER: 342700328
VISIT DATE: 04/15/2024
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LPA Requested the following documents for facility file:

LIC 308 Designation of Facility Responsibility
LIC 500 personnel report
LIC 610D Emergency Disaster Plan
Client Roster
Facility sketch

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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