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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701176
Report Date: 07/21/2025
Date Signed: 07/21/2025 12:49:39 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/21/2025 12:49 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 HOME IIFACILITY NUMBER:
342701176
ADMINISTRATOR/
DIRECTOR:		FUENTES, FLORINDAFACILITY TYPE:
735
ADDRESS:5316 NECTAR CIRCLETELEPHONE:
(916) 897-3834
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: 4DATE:
07/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Florinda Fuentes, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Renee Campbell arrived at the facility to conduct an unannounced annual inspection on 07/21/2025.  LPA met with Florinda Fuentes, Administrator and explained the purpose of the visit.

There were four residents living in the community. Upon entry, two (2) residents were observed preparing to leave for day program. One resident was getting his face shaved and another resident was sitting on the couch. All residents had eaten breakfast for the day.

LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve three (3) ambulatory and one (1) non-ambulatory resident.  LPA Campbell observed the facility to be free of odor, clean and in good repair. LPAs observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Campbell observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured in the kitchen and bathroom. The kitchen water temperature measured at 113 degrees Fahrenheit (F) and the resident bathroom water temperature measured at 114 degrees F. Fire extinguishers, smoke and carbon monoxide detectors are in good repair. The fire extinguisher was last inspected on 05/19/2025 and the smoke/carbon monoxide alarms were tested and found to be functioning. Facility thermostat observed at 70 degrees Fahrenheit. LPA Campbell checked medication storage and found medication to be locked away and inaccessible to clients. First aid kit was complete and contained scissors, tweezers and bandages. A therrmometer was observed in the community as well; LPA requested staff files for review. LPA reviewed 3 staff files of 22 staff. Toxins were made inaccessible to clients in care. Toxins were stored in a storage closet near the bedrooms and was observed to be locked.
The following documents will be email to LPA Campbell (Renee.Campbell@dss.ca.gov) 08/01/2025 by by 5:00 PM by end of day:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate   
(4) LIC 610 Emergency Disaster Plan

Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facility
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2025
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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