342701299-12-5-2025-27-AS-CTAO-DP3SG9-20251205125135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701299
Report Date: 12/05/2025
Date Signed: 12/05/2025 12:52:08 PM

Document Has Been Signed on 12/05/2025 12:52 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:	EVA LUIS RESIDENTIAL II		FACILITY NUMBER:	342701299
ADMINISTRATOR/ DIRECTOR:	MANIQUIZ, LUIS		FACILITY TYPE:	735
ADDRESS:	8106 SAN REMO WAY		TELEPHONE:	(916) 346-5602
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY: 4		CENSUS: 2	DATE:	12/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Luis Maniquiz		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/5/25, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct an annual inspection. LPA met with facility administrator care staff,Luis Maniquiz (S1) and care staff 3 (S3) and explained the purpose of the visit. An entrance interview was conducted with S1 and S3. The facility is licensed for age range 18 through 59. Approved for four (4) ambulatory, of which one (1) may be non-ambulatory in room 4. The current census is two resident and two staff, R1 stayed home from Day Program due to having a cough and R2 was observed to arrive with S1 at around 11:50 PM. S1 reported they and R2 were out on a community outing. At around 12:00PM, LPA observed one resident in the living room and the other in their bedroom. LPA and S3 inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of five residents. The facility temperature was 69 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 112.1 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA observed first aid supplies, a fully - charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA observed there was not a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. S2 stated they will replenish food inventory by end of day 12/6/25. LPA observed a locked cabinet for the storage of medication. LPA observed locked cabinets for the storage of cleaning solutions and knives. The last fire drill was completed 12/3/2025. Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: EVA LUIS RESIDENTIAL II	FACILITY NUMBER: 342701299
	VISIT DATE: 12/05/2025

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LPA requested resident and staff files for review. LPA reviewed two (2) staff files and two (2) resident files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following forms were collected by LPA and will be added to the facility file:
• LIC 500 Personnel Record
LIC 308 Designation of Administrative Responsibility

• Updated LIC 500 Personnel Report
• LIC 9020 Register of facility clients/residents
• Copy of Administrator Certificate(s)

The following forms to be submitted by 12/12/2025 to Cynthia.tamayo@dss.ca.gov:
-LIC 309 Designation of Administrative Responsibility
-LIC 610 Emergency Disaster Plan and Proof of Current Liability Insurance
-Annual Fee payment

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 no deficiencies were cited during this visit. Technical assistance was provided as described above. An exit interview was conducted and a copy of this report was left with S1.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

LIC809 (FAS) - (06/04)

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