342701176-7-30-2026-27-AS-AVIA-DWGR6W-20260730124525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701176
Report Date: 07/30/2026
Date Signed: 07/30/2026 12:45:53 PM

Document Has Been Signed on 07/30/2026 12:45 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 II		FACILITY NUMBER:	342701176
ADMINISTRATOR/ DIRECTOR:	FUENTES, FLORINDA		FACILITY TYPE:	735
ADDRESS:	5316 NECTAR CIRCLE		TELEPHONE:	(916) 897-3834
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY: 4		CENSUS: 4	DATE:	07/30/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:29 AM
MET WITH:	Florinda Fuentes		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On July 30, 2026, Licensing Program Analysts Arvin Villanueva (LPA), arrived unannounced at this facility to conduct the annual inspection visit. LPAs met with the administrator, Florinda Fuentes (AD) and stated the purpose of the visit. Upon arrival, there were one client in care with two staff on duty. Per staff, the other clients were out in the community at this time. Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 4 adult residents, up to 1 may be non-ambulatory in bedroom #3 of the facility sketch. Facility does not have clearance for bedridden, delayed egress, and locked exterior/interior. Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, dining room and outdoor areas. LPA and AD inspected 4 of 4 resident bedrooms and 3 of 3 bathrooms. Hot water temperature was measured at 111 degrees Fahrenheit in one hallway bathroom. Hallway temperature was maintained at 70 degrees Fahrenheit during this visit. No fire door was observed to be closed. In the kitchen area, LPAs observed at least 7-day nonperishable and 2-day perishable food supplies. Refrigerator and freezer were within regulatory temperature. Knives/sharps and cleaning solutions were locked. Fire extinguishers observed and last serviced on 6/10/2026. LPA observed the fire extinguisher to be in a locked cabinet in the kitchen and can only be accessed using a magnetic key. Per staff, they have a client in care who has a history of grabbing this item and throwing it. Smoke detectors were observed throughout and at least one carbon monoxide detector was observed. Medication cabinet was observed to be locked and not accessible to residents. {1 of 2}

Stephen Richardson
Arvin Villanueva
	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

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 II	FACILITY NUMBER: 342701176
	VISIT DATE: 07/30/2026

NARRATIVE

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Outdoor area was inspected. Walkways and ramps were unobstructed. Fences and the exit gate need non-immediate repair. Part of the fence on the side of the facility was observed to be leaning. The exit gate drags at the bottom when LPA swung it open. Per AD, they started planning to repair the fences. No bodies of water were observed at this time. AD was advised that there should be a shaded area for outdoor activities. Per AD they have one but has not put it up yet. 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.
Record Reviews:
Review of 4 of 4 client files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, and Ambulatory Status. Per review of Physician’s Reports, Client-1 (R1) and Client-2 (R2) were assessed as non-ambulatory. Per review of there documents, they were assessed as ambulatory. Per interview with AD, she stated both of these clients are ambulatory. Additionally, Client-4 (R4)’s current Physician’s Report was incomplete – page 2 was not completed including ambulatory status. At this time, LPA is unable to determine the ambulatory status of three clients. AD was advised to have these clients reassessed by their physician.
Medication review was conducted for 2 clients, including review of resident’s medication, PRN authorization letter, prescription records, Centrally Stored Medication Records, and Medication Administration Records. No issues were noted at this time.
P&I (money) was reviewed for 4 of 4 clients. AD counted their money. No issues at this time.
Review of 4 staff files included but not limited to background clearance, first aid/CPR certification, and training. Per review of Guardian, these 4 staff were associated to this facility.
Facility conducts monthly Fire Drill. Advisory was provided to conduct other types of disaster drills as required. Advisory provided to facility to review their Emergency Disaster Plan and Infection Control Plan at least annually and document each review.
Interviews: 1 staff members and 1 residents in care.
Documents Requested: LPA requested a copy of updated Liability Insurance, LIC500, and LIC308 and updated Physician's Reports for R1, R2, and R4.
Per the California Code of Regulations, Title 22, Division 6, Chapter 6 and Health and Safety Code no deficiencies were cited. Advisories were provided.
Exit interview with AD. A copy of the report was provided.
{2 of 2}

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC809 (FAS) - (06/04)

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