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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700661
Report Date: 02/25/2025
Date Signed: 02/25/2025 04:53:18 PM

Document Has Been Signed on 02/25/2025 04:53 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/
DIRECTOR:
BROWN, PAMELA & MAGANA, LUFACILITY TYPE:
735
ADDRESS:400 OLIVINE AVENUETELEPHONE:
(510) 385-8463
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 4CENSUS: 2DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Casey JonesTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analysts (LPA'S) Kesha Lewis and Nole Wolfperterson arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by staff and explained the purpose of the visit.

LPA and staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 4 bed facility with a current census of 2. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. LPA also conducted the care tool. No bodies of water were observed at the facility.

Hot water temperature was measured at 110 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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: 02/25/2025
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LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

LPA observed, fire extinguishers inspected on 10/15/2024 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance.

LPA reviewed two (1) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. One staff members file was not present at the facility and was unable to be reviewed. Facility is conducting initial and continuing training as required.



LPA reviewed one (1) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place.

Exit interview held with staff and copies of reports left at conclusion of visit.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2025 04:53 PM - It Cannot Be Edited


Created By: Kesha Lewis On 02/25/2025 at 01:36 PM
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: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above in 1 out of 3 staff files LPA requested to review were not present at the facility. LPAs being unable to review all staff records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2025
Plan of Correction
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Licensee has agreed to ensure all staff files are complete, A statement of correction, will be completed and submitted into CCL by the due date COB.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
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