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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002923
Report Date: 04/30/2025
Date Signed: 05/01/2025 04:47:36 PM

Document Has Been Signed on 05/01/2025 04:47 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:REMOLONA FAMILY GUEST HOMEFACILITY NUMBER:
397002923
ADMINISTRATOR/
DIRECTOR:		NORA REMOLONAFACILITY TYPE:
740
ADDRESS:360 BUTTON AVENUETELEPHONE:
(209) 823-9122
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 15TOTAL ENROLLED CHILDREN: 0CENSUS: 15DATE:
04/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jon and Nora RemolonaTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Unannounced Annual visit made out to this facility on 04/30/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff persons, Maria Lourdes Vazquez and Rosalinda Wright, who were briefly interviewed at this time. This LPA requested that they go ahead and contact the facility designated Administrator, Nora Remolona, to inform her that CCL was present at this time for an annual visit. The facility designated Administrator arrived later to this facility while this LPA was conducting this visit.
Current census was 15 residents.
It was learned that there were (4) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (6) residents under the care of hospice at any given time.
It was learned that there were (5) resident receiving services through home health at this time.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located in facility hallway, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured.
Kitchen drawers and cabinets were opened and reviewed.
Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured.
Additional food storage units located in the garage area were observed to be present and functional at this time.
Liza KingTELEPHONE: (650) 676-0442
Charlie YangTELEPHONE: (916) 709-6507
DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: REMOLONA FAMILY GUEST HOME
FACILITY NUMBER: 397002923
VISIT DATE: 04/30/2025
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Laundry room, located as part of the garage, was toured.
Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the
residents at this time.
Administrator certificate, # 7007799740, for Nora Remolona was observed to have an expiration date of 11/01/2026 and in compliance at this time.
Forms and documents have been completed in order to renew this Administrator certificate at this time.
Medication cabinet, located in the facility kitchen cabinet, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the medication closet, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguishers were located throughout this facility and observed to have been annually inspected by the local fire extinguisher company, ARF Fire Extinguisher Company, on 03/05/2025 and found to be in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
A review of (4) facility personnel records was conducted on the LIC 859.
A review of (5) facility resident records was conducted on the LIC 858.
The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308
LIC 400
LIC 500
LIC 610

There were no deficiencies observed or cited during today's annual visit. Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC809 (FAS) - (06/04)
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