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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700661
Report Date: 12/06/2024
Date Signed: 12/06/2024 11:31:55 AM

Document Has Been Signed on 12/06/2024 11:31 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CASA DE ESPERANZAFACILITY NUMBER:
392700661
ADMINISTRATOR/
DIRECTOR:		BROWN, PAMELA & MAGANA, LUFACILITY TYPE:
735
ADDRESS:400 OLIVINE AVENUETELEPHONE:
(510) 385-8463
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 4CENSUS: 2DATE:
12/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Pamela Brown TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to conduct a case management visit stemming from a complaint. LPA was greeted by Licensee and explained the reason for the visit.

During the course of the investigation it was discovered that a staff member (S2) is not associated to the facility.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, Deficiencies are being cited during this meeting. See 809D page.

Exit interview conducted. copy of report and appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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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Document Has Been Signed on 12/06/2024 11:31 AM - It Cannot Be Edited


Created By: Kesha Lewis On 12/06/2024 at 09:35 AM
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: CASA DE ESPERANZA
FACILITY NUMBER: 392700661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
12/11/2024
Section Cited
CCR
87411(g)(2)

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) Personnel Requirements – General
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(2) Request a transfer of a criminal record clearance...
This requirement was not met as evidence by:
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Administrator will also review the regulation cited and provide LPA a statement of acknowledgement and understating of the regulation cite. POC due to LPA by 12/11/24 end of day 5:00 PM.
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This requirement was not met as evidence by: Based on interviews, observations and record review, R2 is working at the facility but not associated. the licensee did not ensure staff has been associated to the facility. This posed a potintial health and safety risk residents in care.
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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:Liza King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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