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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701204
Report Date: 12/13/2023
Date Signed: 12/13/2023 12:44:16 PM


Document Has Been Signed on 12/13/2023 12:44 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
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: 3DATE:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Elaine Abengana - Direct Care StaffTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted a required 1 year annual inspection visit. LPA met with direct care staff and explained purpose of visit.

LPA and direct care staff conducted a tour of the home. The facility is a single story home located in a residential neighborhood. The facility contains five bedrooms, four resident bedrooms and one staff bedroom. LPA observed two bathrooms, one in the resident hallway and a second in the staff bedroom. Facility has obtained a fire clearance for four non-ambulatory residents. LPA observed the home to be clean sanitary and in good repair. Fire extinguishers purchased November 22, 2023 and first aid kit is complete. Hot water temperature recorded as 111.5 degrees F which meets the 105-120 degree Fahrenheit regulation 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 direct care staff 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.
LPA reviewed two resident and three staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility.

LPA Requested the following documents for facility file to be sent via email by December 20, 2023 : LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, Copy of Surety Bond, Current Administrator Certificate and .
ruth.wallace@dss.ca.gov

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection.

An exit interview was conducted with direct care staff. A copy of this report and (LIC 811 - Confidential Names) was left at the facility.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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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