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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004430
Report Date: 03/25/2025
Date Signed: 03/27/2025 08:21:51 AM

Document Has Been Signed on 03/27/2025 08:21 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:POPO'S PLACEFACILITY NUMBER:
347004430
ADMINISTRATOR/
DIRECTOR:		RACHEL MILESFACILITY TYPE:
740
ADDRESS:7672 EASTGATE AVENUETELEPHONE:
(916) 961-6248
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
03/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Kim Rosa, House Manager TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with caregiver staff, Luz Jimenez, and explained purpose of inspection. Kim Rosa, House Manager, arrived at 11:30 am. LPA observed (4) residents watching television in the common area and was advised (1) resident was attending a medical appointment. There is currently (1) resident under hospice care.

LPA and manager toured the interior/exterior of the facility including the common areas, (4) private resident bedrooms (1) shared resident bedroom, (2) resident bathrooms, (1) staff room, kitchen and laundry area, and garage area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. There is sufficient 2+day perishable and 7+day non-perishable supply of food, and sharps, medications and toxins are locked in the kitchen. There are additional locked toxins in the laundry area. The inside temperature measured 72*F and the hot water measured 125*F in the kitchen. Sign posted near the sink. Water temperature was turned down and will be checked monthly to ensure it's within range of 105-120*F. The smoke/monoxide alarms are working and the fire extinguisher was last serviced 2/28/2025. There are sufficient linens/towels/blankets and paper supplies, including PPE. There are (2) unlocked exits in the backyard. There are no pools with water.LPA reviewed (2) of (4) resident files and found them to be organized and contain current physician's reports and appraisals. Medications were reviewed for (1) residents- orders on file matched medications being administered. LPA reviewed (3) staff files- files are complete and contain current training documentation, including for First Aid/CPR. Discussed updated Dementia care regulations and provided copy of Regulation 87463. LPA requested an updated copy of the LIC308, LIC500 and current liability insurance be provided by 3/19.
Exit interview. Copy of report provided.
Maribeth SentyTELEPHONE: (916) 263-4813
Sabrina CalzadaTELEPHONE: (510) 829-2133
DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
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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