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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004992
Report Date: 01/25/2024
Date Signed: 01/25/2024 10:28:37 AM

Document Has Been Signed on 01/25/2024 10:28 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:ESPINOZA CARE HOMEFACILITY NUMBER:
347004992
ADMINISTRATOR:ESPINOZA, ALFREDOFACILITY TYPE:
735
ADDRESS:5440 LIBERTY STREETTELEPHONE:
(916) 550-8053
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 4CENSUS: 3DATE:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Ron AysonTIME COMPLETED:
11:00 AM
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On January 25, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived at the facility to conduct the Annual inspection. LPA met with administrator, Ron Ayson and explained the reason for the visit.

Ron and LPA conducted the infectious Control questionnaire with no issues.

LPA inspected the interior and exterior of the facility. In the kitchen there were no issues.
This is a four bedroom two bath home. The bed rooms and bathrooms were very clean and had all the furnishing they are required to have. LPA reviewed three clients files.
All documents were up to date .

Fire extinguishers was ready for emergency use. First Aid kit had all the required
items such as scissors, thermometer and guide.

No citations given today.

An exit interview was conducted and a copy of this report was given to Ron.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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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