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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700661
Report Date: 06/26/2024
Date Signed: 06/26/2024 03:02:42 PM

Document Has Been Signed on 06/26/2024 03:02 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
06/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Pamela BrownTIME COMPLETED:
12:00 PM
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Unannounced Annual visit made out to this facility on 06/26/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Pamela Brown and Luis Magana. A brief interview was conducted with the facility designated Administrator at this time.
This facility was vendorized at this time to accept and retain Level 3 regional center clients at this time.
Current census was zero residents.
It was learned that there weren't any residents under the care of hospice at this time.
It was learned that there weren't any residents diagnosed with dementia at this time.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time for facility designated back up Administrator Luis Magana. Additional forms and documents were reviewed to make sure that the certificate # 6047705735 was due to expire on 10/24/2024 and in compliance at this time.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinet and supplies, located in the facility office bedroom, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator at this time. This medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Linen closets were observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CASA DE ESPERANZA
FACILITY NUMBER: 392700661
VISIT DATE: 06/26/2024
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Laundry area was toured. It was observed that all detergents and bleach were centrally stored and locked in the garage area and made inaccessible to the residents at this time.
Fire extinguisher, located in the kitchen cabinet, was observed to have been annually inspected on 01/10/2024 by the local fire extinguisher company, Assured Fire Inc, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.

Since there were no residents in care, a review of the facility resident records was not conducted at this time.

A review of (2) facility staff records was conducted and noted on the following LIC 859 form.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
LIC809 (FAS) - (06/04)
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