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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700661
Report Date: 02/17/2022
Date Signed: 02/17/2022 01:57:36 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/17/2022 01:57 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:CASA DE ESPERANZAFACILITY NUMBER:
392700661
ADMINISTRATOR:BROWN, PAMELA & MAGANA, LUFACILITY TYPE:
735
ADDRESS:400 OLIVINE AVENUETELEPHONE:
(510) 385-8463
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 4CENSUS: 0DATE:
02/17/2022
TYPE OF VISIT:Annual/RandomANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Louis MaganaTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived announced to conduct an annual inspection. LPA met with Louis and explained the purpose of the visit.

There are no residents in care at this time the facility is waiting to be vendorized by Valley Mountain Regional Center.

LPA inspected the physical plant. LPA observed sufficient furniture and lighting throughout the facility. Hot water temperature was measured at 110 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and Smoke detectors are operational. LPA observed where centrally stored medications will be locked.

First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility.

No deficiencies were observed.

Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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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