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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701204
Report Date: 12/23/2022
Date Signed: 12/23/2022 11:07:15 AM

Document Has Been Signed on 12/23/2022 11:07 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:NORTHSTAR CAREHOMEFACILITY NUMBER:
342701204
ADMINISTRATOR:ABENGANA, JERRY Y.FACILITY TYPE:
735
ADDRESS:3469 DURELLO CIRCLETELEPHONE:
(909) 525-8758
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 4CENSUS: 0DATE:
12/23/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jerry AbenganaTIME COMPLETED:
11:30 AM
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on 12/23/22 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at Northstar Carehome Adult Residential Facility (ARF) for the purpose of conducting a pre-licensing inspection. LPA met with Licensee Jerry Abengana and together conducted a tour of the home.

The facility is a single story home located in a residential neighborhood. The facility contains 5 bedrooms, 4 resident bedrooms and one staff bedroom. LPA observed two bathrooms, one in the resident hallway and a second in the staff bedroom. Requested capacity is for 4 residents and has obtained a fire clearance for 4 non-ambulatory residents. LPA observed the home to be clean sanitary and in good repair. Fire extinguisher and first aid kit meets regulations. Hot water temperature recorded as 109 degrees F. which meets regulations. all sharp objects and cleaning supplies are made inaccessible to residents in care. LPA observed appropriate seating to accommodate the requested capacity. No cameras were observed in the facility.

LPA and licensee conducted a tour of the back yard. LPA observe a fountain/waterfall and small pond that was entirely fenced and made inaccessible to residents in care. LPA observed no outdoor obstructions. The back yard has required outdoor seating and shade to meet resident needs.

Per California Code of Regulations, Title 22 there were no deficiencies observed or cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.

LPA has no objections to the facility being licensed.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2022
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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