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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001747
Report Date: 06/26/2023
Date Signed: 06/26/2023 04:27:43 PM

Document Has Been Signed on 06/26/2023 04:27 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DONNIE AND CECILIA PESTRANA FAMILY HOME #2FACILITY NUMBER:
347001747
ADMINISTRATOR:PESTRANA, CECILIAFACILITY TYPE:
735
ADDRESS:8212 CONOVER DRIVETELEPHONE:
(916) 721-6911
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 5DATE:
06/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Lisa Pestrana, Lead caregiver TIME COMPLETED:
04:30 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's) Sabrina Calzada and Jaynae Boyles arrived unannounced to conduct a required annual inspection. LPA met with Lisa Pestrana, Lead caregiver/DSP, and explained purpose of inspection. Cecilia Pestrana, Administrator, arrived at approximately 2:00 pm. The facility is an ARF (level 3 home) that is vendorized through Alta California Regional Center. There are (6) clients who reside at the home. LPA observed (5) clients in the facility and was advised (1) client was at work. Currently, there is remodeling being done in one client bathroom. The facility is a two-story home and staff reside on the second floor. The fire clearance was approved for (6) ambulatory clients.

LPA's, Administrator and DSP toured the interior and exterior of the facility including the common areas, (3) shared client bedrooms, (2) client bathrooms, kitchen, laundry area/garage, sun room. LPA observed the home to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. LPA observed various Covid posters throughout as well as other required postings, including House Rules and personal rights. Inside temperature was observed to be 78* F. Fire extinguisher last serviced 12/8/2022. Facility conducts monthly fire and disaster drills, at different hours of the day. The facility has a large back yard area with seating. There are no pools/ponds. LPA's observed locked toxins in the laundry area and locked medications in a separate cabinet. LPA's observed sufficient 2+day perishable/7+day non-perishable food and sufficient PPE on hand. LPA's observed paper towels, soap, sanitizer, trash cans and hand-washing posters in the bathroom. Water temperature measured 114* in the kitchen. Smoke/monoxide alarms were in working order. Games/activities observed on site.

LPA's reviewed (2) client files and (2) staff files and found the required documentation on file, including staff training. LPA's reviewed P&I funds and medications for (2) residents and found no errors. The facility did not have an Infection Control Plan or a current/updated Emergency Disaster Plan on file. LPA's requested updated LIC308 and LIC500 to be submitted within a week to CCLD.
There were deficiencies found during today’s inspection. Deficiencies are cited from California Code of regulations, Title 22, and citations are listed on the attached LIC809D pages. If the deficiency is not corrected by the noted due date civil penalties may bassessed. Exit interview.
Copy of report and appeal rights given.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2023
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 3
Document Has Been Signed on 06/26/2023 04:27 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 06/26/2023 at 03:54 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DONNIE AND CECILIA PESTRANA FAMILY HOME #2
FACILITY NUMBER: 347001747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)
Infection Control Requirements
A licensee shall ensure that infection control practices are maintained as follows: 

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 1 Infection Control plans which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2023
Plan of Correction
1
2
3
4
Licensee/Administrator agree to complete an Infection Control Plan and submit to the Department by 7/10/23.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Maribeth Senty
LICENSING EVALUATOR NAME:Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/26/2023 04:27 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 06/26/2023 at 03:57 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DONNIE AND CECILIA PESTRANA FAMILY HOME #2
FACILITY NUMBER: 347001747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 1 disaster plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2023
Plan of Correction
1
2
3
4
Licensee/Administrator agree to complete an Emergency Disaster Plan (LIC610E) (9 page version) and submit to the Department by 7/10/23,
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Maribeth Senty
LICENSING EVALUATOR NAME:Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3