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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701204
Report Date: 12/20/2024
Date Signed: 12/20/2024 11:43:35 AM

Document Has Been Signed on 12/20/2024 11:43 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NORTHSTAR CAREHOMEFACILITY NUMBER:
342701204
ADMINISTRATOR/
DIRECTOR:		ABENGANA, JERRY Y.FACILITY TYPE:
735
ADDRESS:3469 DURELLO CIRCLETELEPHONE:
(916) 476-3555
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 4CENSUS: 4DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jerry AbenganaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 12/20/24. LPA identified herself upon arrival, stated the purpose of the visit. LPA met with Jerry Abengana and a brief interview followed. LPA requested the following documents:
 
·LIC 500: Personnel Report
·LIC 308: Designation of Administrative Responsibility
·LIC 309: (for any LLC or Corp) if applicable
·LIC 402: Surety Bond, if applicable
·LIC 610E: Emergency Disaster Plan
·Copy of Liability Insurance
 
LPA noted the Administrator's certificate # 7026319735 and it expires on 10/08/25.

The LPA inspected the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. All food items were dated, labeled, and stored according to regulations. 

The fire extinguisher was last serviced on 11/08/24 by Hogue Fire Protection and was in compliance at the time of inspection.

LPA inspected resident rooms. All 4 rooms were single occupancy and had the required furniture, furnishings and lighting to be in compliance at the present time. The doors to all of the rooms were also equipped with locks for residents to use if they so chose.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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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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: NORTHSTAR CAREHOME
FACILITY NUMBER: 342701204
VISIT DATE: 12/20/2024
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LPA inspected the bathrooms. Each contained soap, paper towels, grab bars and trash cans as required Personal hygiene items were present, toxic cleaning supplies were not. Hot water was measured to ensure the temperature was between 105 and 120 degrees Fahrenheit in order to be in compliance. Hot water measured 113.2 degrees F.

LPA inspected the laundry room and garage.  The garage contained locked cabinets where laundry detergent and other cleaning supplies were stored for staff use. 

The LPA observed medications were stored in a locked cabinet in the dining room and inaccessible to residents in care. LPA reviewed storage and destruction procedures. LPA reviewed the Centrally Stored Medication Log as well as the Destruction Log and both were in compliance at the time of this inspection. LPA reviewed the PRN Log to ensure that it was also in compliance.  The first aid kit was also inspected to ensure it contained all of the required elements. LPA found it to be in compliance at the time of inspection.

The LPA and the Administrator then inspected the exterior of the building and grounds. There was a pond with a waterfall that was completely fenced in and inaccessible to residents in care. There was a patio area with furniture for residents to enjoy. All window screens and gutters were in good repair at the time of inspection. There was a locked storage unit present in the backyard. Upon inspection the LPA found it contained furniture and cushions.  
 
LPA observed an activity calendar, menu calendar, facility license, IF YOU SEE SOMETHING, SAY SOMETHING sign, along with resident and employee rights flyers.

LPA reviewed LIC 500 and compared it to the Guardian Roster to ensure that all the employees had their required background clearances.  All were in compliance at the time of this inspection. All staff files reviewed also contained current CPR/First Aid certificates.

LPA conducted a file review for 2 residents. All were in compliance at the time of this inspection. 

According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided. Exit interview.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC809 (FAS) - (06/04)
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