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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700544
Report Date: 04/27/2023
Date Signed: 04/27/2023 03:50:32 PM

Document Has Been Signed on 04/27/2023 03:50 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CISTERS LOVING CARE HOMEFACILITY NUMBER:
342700544
ADMINISTRATOR:CISTER, ROCHELLE HFACILITY TYPE:
735
ADDRESS:9837 LUCCA WAYTELEPHONE:
(916) 897-3098
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: 4DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rochelle H. CisterTIME COMPLETED:
04:10 PM
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On 4/27/2023, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. LPA met with Assistant Administrator Florinda Fuentes and explained the purpose of today’s visit. Administrator Rochelle H. Cister arrived shortly after. Administrator holds current certification #6050060735 and expires on 11/26/2024. The facility is licensed for 4 ambulatory clients of which 1 is non-ambulatory. There are currently 4 clients who reside at this facility.

LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and backyard area of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. The hot water temperature was observed to be 113.5 degrees Fahrenheit. Facility thermostat observed at 69 degrees Fahrenheit. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. Proof of current liability insurance was observed.

LPA requested client and staff files for review. LPA reviewed (4) client files and (3) staff files, including criminal record clearances. LPA reviewed staff associations to the facility. A full Care Tool Inspection was completed at facility.

Report continued on 809-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CISTERS LOVING CARE HOME
FACILITY NUMBER: 342700544
VISIT DATE: 04/27/2023
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Administrator was informed to send updated copies of the following documents to CCL within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) LIC610 Emergency Disaster Plan

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection.

Exit interview held with Administrator and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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