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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700544
Report Date: 05/26/2026
Date Signed: 05/26/2026 05:27:10 PM

Document Has Been Signed on 05/26/2026 05:27 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:CISTERS LOVING CARE HOMEFACILITY NUMBER:
342700544
ADMINISTRATOR/
DIRECTOR:		FUENTES, FLORINDAFACILITY TYPE:
735
ADDRESS:9837 LUCCA WAYTELEPHONE:
(916) 897-3098
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: 4DATE:
05/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Rochelle Cister, LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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On May 26, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct the annual inspection visit. LPA initially met with the staff on duty, Ronald Cabiles (S1) and stated the purpose of the visit. The licensee, Rochelle Cister (AD), was notified and arrived shortly after.

Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 4 adult residents, one of which may be non-ambulatory. Facility does not have clearance for bedridden, delayed egress, and/or locked interior/exterior. Facility does manage resident cash resources. Facility does not have hospice waiver. Bedroom #4 is cleared for non-ambulatory use. This facility is vendored by a Regional Center.

Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas.

LPA inspected 4 resident bedrooms and 2 bathrooms. Bathrooms are equipped with non-skid flooring. In one of the toilet, there was no grab bar installed; however, all residents were assessed as ambulatory. Advisory was provided to install a grab bar. Faucet, toilet and shower are in working condition. Hot water temperature was 106 degrees Fahrenheit in one of the bathrooms. Room temperature was maintained at 70 degrees Fahrenheit throughout this visit.

In the kitchen/dining area, LPA observed at least 7-day nonperishable and 2-day perishable food items. Knives/sharps and cleaning chemicals were locked under the sink. Fire extinguishers were observed in the kitchen area and last serviced on 7/23/25.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: CISTERS LOVING CARE HOME
FACILITY NUMBER: 342700544
VISIT DATE: 05/26/2026
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Fireplace was observed to be screened. Smoke detectors and carbon monoxide detectors were observed throughout. One was tested by staff and found to be in good working condition. Residents do not have access to the garage - it is locked.

The exit at the kitchen area going to the backyard does have a ramp. Outdoor area was inspected. Walkways were observed to be unobstructed. Fence and gate were in good repair at this time. No bodies of water were observed at this time. There is a shaded area for outdoor activities. LPA observed outdoor furniture. Shut-off valves were located. Advisory was provided to ensure all staff know the location of each of the shut-off valves and know how to operate each one in case of emergency. Cameras were observed at the front of the property.

Record Reviews: Review of 2 of 4 resident files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, and Ambulatory Status. Advisory was provided to obtain an updated Individual Program Plan (IPP) report for one of the residents from their service coordinator.

Medication review was conducted for 2 residents, including review of resident’s medication, PRN authorization letter, prescription records, Centrally Stored Medication Records, and Medication Administration Records. PRN Authorization letters were on file.

Review of 2 residents’ P&I (money) records was conducted. No issues noted.

Review of 5 staff files included but not limited to background clearance, first aid/CPR certification, and training.

Fire/Emergency Drill was last conducted on 5/17/26. Advisory provided to facility to review their Emergency Disaster Plan and Infection Control Plan at least annually and document each review.

Interviews: 1 resident interviewed and 2 staff interviewed. Advisory provided to facility to review their abuse training, medication training, and personal rights training.

Documents Requested: LPA requested a copy of updated Surety Bond, LIC500, and LIC308.

Per the California Code of Regulations, Title 22, Division 6, no deficiencies were cited.

Exit interview was conducted with AD. A copy of the report was provided upon exit.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC809 (FAS) - (06/04)
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