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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700661
Report Date: 02/27/2023
Date Signed: 03/03/2023 09:47:46 AM

Document Has Been Signed on 03/03/2023 09:47 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
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:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Pamela Brown and Luis MaganaTIME COMPLETED:
10:30 AM
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On 02/22/2023 at 9:00am, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual visit. LPA Pascua rang the door bell twice and there was no answer at the door. LPA Pascua called the facility number on file and no one answered the phone. LPA Pascua left a voicemail with a return number. LPA Pascua will return at another time to complete the annual visit.

On 02/27/2023, at 9:00am, Licensing Program Anyalst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual visit. LPA Pascua rang the door bell twice and there was no answer at the door. LPA Pascua called the facility number on file and no one answered the phone. LPA Pascua left a voicemail with a return number. LPA Pascua will return at another time to complete the annual visit.

On 03/03/2023 at 8:45am, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual visit. LPA Pascua was greeted and met with Licensee, Pamela Brown and Facility Designated Administrator, Luis Magana and explained the purpose of the visit. The purpose of the visit is to conduct an Annual Visit. This facility is licensed to serve 4 ambulatory residents and is vendorized by Valley Mountain Regional Center to hold and accept Level 3 residents at this time.
There are no current residents residing at this facility at this time.
LPA reviewed 2 staff files. 2 out of 2 staff files are up to date. The Licensee hold a current and active certificate #601576735 and expires on 06/09/2024. The Facility Designated Administrator has a current administrator certificate and is awaiting for the department to renew.
LPA Pascua initiated a tour with Licensee Brown and FDA Magana. Fire extinguisher located in the kitchen was serviced by AAA Restaurant Fire Control, INC on 10/28/2022.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ESPERANZA
FACILITY NUMBER: 392700661
VISIT DATE: 02/27/2023
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First Aid Kit was present and contained all of the required components.
A tour of the garage was conducted. Additional storage for supplies were identified.
A tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies will be located in the staff office and made inaccessible to the residents at this time.
A tour of the 3 resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of the staff bedroom was also conducted.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.
The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.
Exit interview.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC809 (FAS) - (06/04)
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