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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 11:07:33 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 Licensing Program Analyst (LPA) Kevin Gould conducted a component III pre licensing at Northstar Carehome meeting with Administrator Jerry Abenganar. LPA Gould, Administrator and Licensee went over the component 3 powerepoint.

LPA Gould discussed Operating Requirements, Physical Environment, Personnel Requirements, Resident Records, Health Related Services and Conditions.

LPA discussed the department's and LPA's responsibilities and the responsibilities of the Administrator and reporting requirements including but not limited to the forms required for reporting and documenting any changes in resident files.

Exit interview was conducted. Once approved, a copy of the license will be set to the Licensee.
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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