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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701176
Report Date: 06/11/2024
Date Signed: 06/11/2024 04:39:20 PM

Document Has Been Signed on 06/11/2024 04:39 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:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Gil Del Carmen TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required visit. LPA met with facility staff, and explained the purpose of the visit.

Upon arrival, LPA observed 3 staff members and 2 residents. LPA Valerio learned that 1 resident went to a doctor appointment and the other resident was at their Day Program. LPA Valerio observed staff preparing snacks for the residents, doing facility laundry, and cleaning the facility. Staff were observed to be engaging with the residents throughout the facility visit. LPA spoke to staff and residents during the visit.

LPA Valerio and facility staff Gil D. toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed 4 resident bedrooms. Resident bedrooms were individually decorated, clean, free from debris, and fully furnished. Resident bathrooms were observed to be fully stocked and clean. Hot water was measured at 108.0 degrees F, which is within the regulatory range of 105.0-120.0. Common areas, including the staff office, living room, and the kitchen area, were observed to be fully furnished and clean. The facility was observed to have a minimum of seven day non-perishable food items and a two day perishable food items. Cleaning supplies, toxins, medications, and sharps were observed to be locked and inaccessible to residents in care. The temperature inside the home was observed to be 70 degrees. Carbon monoxide detectors, fire detectors, and air conditioning were observed to be in working condition. The fire extinguishers were last maintenance May 23, 2024. The facility conducted a fire drill with residents and staff on June 02, 2024.

LPA Valerio reviewed two (2) staff files and two (2) resident files. Files were observed to be current and complete. LPA requested the following annual documentation be sent to the Regional Office: LIC 500, LIC 308, LIC 610, and copy of surety bond.
Per California Code of Regulations (CCR) - Title 22, no deficiencies were observed during today's visit. An exit interview was held with facility staff, and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
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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