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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700677
Report Date: 03/04/2025
Date Signed: 03/04/2025 03:22:02 PM

Document Has Been Signed on 03/04/2025 03:22 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:MISSION HOME CBN INCFACILITY NUMBER:
342700677
ADMINISTRATOR/
DIRECTOR:		ORLANDO CARPIOFACILITY TYPE:
735
ADDRESS:8591 MISSION FALLS CIRCLETELEPHONE:
(916) 519-7474
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Rona Agoncillo, Facility ManagerTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 3/4/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct their required annual inspection visit. LPA met with facility house manager, Rona Agoncillo (S1), and explained purpose of visit. The facility administrator was notified of this visit and gave permission for Rona to sign this report. Present during today's visit were 3 client in care with 3 staff on duty. Administrator renewed his Administrator Certificate on 9/12/2024.

LPA and S1 inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, and outside backyard. Facility is a one story home located in a residential neighborhood, with 4 bedrooms and 2 bathrooms. The facility serves adult residents with developmental/intellectual disabilities.

LPA observed room temperature at 72 degrees Fahrenheit. LPA observed sufficient furniture and lighting throughout the facility. LPA observed food supplies of at least 7-day non-perishable and 2-day perishable. LPA measured the hot water temperature in resident's bathroom at 110 degrees Fahrenheit which is within regulatory range. Refrigerator and freezer temperatures were within regulatory range.

Fire extinguishers last inspected on 12/12/2024. Smoke detectors and carbon monoxide detectors were tested and found to be in good working condition. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared 1 resident medication vs. medication logs. First aid kit was checked and is complete. The facility conducts fire drills with residents on a monthly basis. Last fire drill was conducted on 2/18/25. Facility also conducts semi-annual disaster drill and last disaster drill was on 12/31/24.

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Stephen RichardsonTELEPHONE: (916) 263-4700
Arvin VillanuevaTELEPHONE: 916-208-0023
DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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
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: MISSION HOME CBN INC
FACILITY NUMBER: 342700677
VISIT DATE: 03/04/2025
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LPA reviewed two client files: Per review, 2 of 2 client contain updated Needs and Services Plan and Medical Assessments. LPA reviewed 2 P&I records and medication records and found to be in compliance at this time.

LPA reviewed three staff files: Per review, 3 of 3 staff have background fingerprint cleared and associated to the facility. 3 of 3 staff have current 1st Aid/CPRcertificate. LPA verified staff training for staff file reviews.

LPA requested the following updated documents to be submitted via email to community care licensing by March 6, 2025: LIC 308 Designation of Administrator, LIC 500 - Personnel Report, Copy of Liability Insurance Certificate, and Copy of Surety Bond. arvin.villanueva@dss.ca.gov

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies cited during this visit.

Exit interview held with administrator. A copy of report was provided.














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SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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