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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000120
Report Date: 06/30/2021
Date Signed: 06/30/2021 12:18:54 PM

Document Has Been Signed on 06/30/2021 12:18 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:CAJUCOM CARE HOME #2FACILITY NUMBER:
347000120
ADMINISTRATOR:EDILBERTO Z CAJUCOMFACILITY TYPE:
740
ADDRESS:3030 EASTERN AVETELEPHONE:
(916) 489-1771
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 12CENSUS: 7DATE:
06/30/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carlomagno Esquillo TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 06/30/2021 at 10:00 am. LPA met with Carlomagno Esquillo and explained the purpose of the visit.

The purpose of the visit today, is in response to an expired administrator certificate. The administrator for Cajucom 2 is Edilberto Cajucom. Edilberto Cajucom's administrator certificate expired on 06/04/2020. Recertification documentation has be been submitted to the CCLD on 04/02/2021, and new certificate is pending.

As a result of this visit, a deficiency was cited, per California Code of Regulations, Title 22 and Health and Safety Code. Exit interview conducted and 809, 809D, and appeals right given to the facility at the end of the visit.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2021
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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Document Has Been Signed on 06/30/2021 12:18 PM - It Cannot Be Edited


Created By: Avelina Martinez On 06/30/2021 at 11:59 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CAJUCOM CARE HOME #2
FACILITY NUMBER: 347000120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2021
Section Cited
CCR
87407(e)

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87407(e) Administrator Recertification Requirements: To apply for recertification after the expiration date of the certificate, but within four (4) years of the certificate expiration date, the certificate holder shall submit to the Department’s Administrator Certification Section:
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Administrator submitted recertification documents on 04/02/2021. Adminstrator agrees to provide weekly recertification updates to CCLD until recerification approved.
In addition, the Adminstrator agrees to provide a copy of new adminstrator certificate to CCLD by 07/15/2021.
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This requirement was not met as evidence by: Based on observation and file review, The adminstrator did not ensure to renew adminstrator certificate. The andmistrator certificate expired on 06/04/2020.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2021


LIC809 (FAS) - (06/04)
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