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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701350
Report Date: 06/17/2024
Date Signed: 06/19/2024 10:15:21 AM

Document Has Been Signed on 06/19/2024 10:15 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:LA HACIENDA CARE MANTECA, LLCFACILITY NUMBER:
392701350
ADMINISTRATOR/
DIRECTOR:
VALLARTA, ANABELEN D.FACILITY TYPE:
740
ADDRESS:597 HACIENDA AVENUETELEPHONE:
(510) 709-7078
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 0DATE:
06/17/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Anabelen VallartaTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Announced Prelicensing visit made out to this facility on 06/17/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility Applicant, Anabelen Vallarta, at this time. A brief interview was conducted with the facility Applicant at this time.
It was learned that this facility was seeking licensure to be able to accept/retain up to (6) residents at any given time.
This facility was seeking licensure for (3) non ambulatory and (3) ambulatory residents with a hospice waiver granted for (2) residents at any given time.
Current census was zero residents.
Tour of this facility was conducted.
A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time.
Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time.
A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.
Medication cabinet, located in the hallway closet, was reviewed. Policies and procedures involving, dispensing, and documentation of the resident medications were discussed with the facility Applicant at this time. A review of the facility Medication Administration Record and dispensing log was conducted.
Medication cabinet was observed to be locked and made inaccessible to the residents at this time.
Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
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: LA HACIENDA CARE MANTECA, LLC
FACILITY NUMBER: 392701350
VISIT DATE: 06/17/2024
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A tour of the resident restrooms was conducted.
Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry area was toured. Cleaning supplies, detergents, and bleach were observed to be present in designated drawers and made inaccessible to the residents at this time.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the garage area was conducted. It was observed that this area had been converted into a staff room at this time. An additional room was observed to be present and will be used as the actual bedroom for the live-in staff.
First aid kit was observed to be present and contained all of the required components at this time.
Fire extinguisher was observed to be placed in the kitchen area and was just recently purchased at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.

This facility and its Applicant was found to be in compliance at this time.

Component III was conducted by this LPA along with the facility Applicant Anabelen Vallarta at this time.

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

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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