<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000175
Report Date: 08/24/2021
Date Signed: 08/24/2021 01:49:12 PM

Document Has Been Signed on 08/24/2021 01:49 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 #1FACILITY NUMBER:
347000175
ADMINISTRATOR:EDILBERTO Z CAJUCOMFACILITY TYPE:
740
ADDRESS:3024 EASTERN AVETELEPHONE:
(916) 483-3033
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 11CENSUS: 6DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Carlomagno Esquillo TIME COMPLETED:
02:00 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
Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to conduct an annual inspection on 08/24/2021 at 10:20 AM. LPA met with Carlomagno Esquillo and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room of the facility to ensure compliance with Title 22 regulations.

Administrator holds expired certificate # 6030833740 and it expired on 06/04/2020. Recertification documentation was submitted to CCLD on 04/05/2021, and administrator certification is pending. The facility is licensed for six non-ambulatory and five ambulatory residents. There are currently 6 residents who reside at this facility.

The LPA toured the facility with Carlomagno Esquillo on 08/24/2021 at :10:30 AM.

During this annual visit, LPA Martinez observed the cleaning progress of this facility. The licensee is currently painting the outside of the facility and removing miscellaneous items from the outside. In addition, the common bathrooms and bedroom are in the process of being painted. The cleaning of the resident bedrooms and common areas is being done. The facility has a LIC 808 mitigation plan and has Covid-19 posting in the facility.

Employee and resident files have been updated and contain the required documents. LPA Martinez reviewed 3 employee files and 3 resident files. LPA Martinez reviewed 3 resident medication files, which were up to date. Fire Department conducted a fire inspection 08/06/2021. The smoke and carbon detectors are in good repair. The facility staff will continue with the following: On going cleaning of the interior and exterior of the facility. Facility staff will continue to conduct record reviews of employee and resident files. Meal Preparation waiver has been submitted to the Department. Moreover, the facility kitchen has perishable and non-perishable foods. The kitchen is clean. As a result of the visit, there were no deficiencies cited. An exit interview was conducted and a report given at the end of the visit.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1