397202943-8-20-2025-27-AS-NWPN-DKQUHK-20250820153605

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397202943
Report Date: 08/20/2025
Date Signed: 08/20/2025 03:36:08 PM

Document Has Been Signed on 08/20/2025 03:36 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:	ESTRELLA'S CARE HOME NO. 3		FACILITY NUMBER:	397202943
ADMINISTRATOR/ DIRECTOR:	ALLAN JOSE		FACILITY TYPE:	735
ADDRESS:	3837 HOLDREGE WAY		TELEPHONE:	(209) 948-2013
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 6		CENSUS: 6	DATE:	08/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	JJ Jose		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst(LPA) Noel Wolf Petersen arrived unannounced to conduct a annual inspection at 1:30 on 8/20/25. The LPA met with the administrator JJ Jose to explain the purpose of the visit. Estrella's care home No. 3 is a 6 capacity Adult residential Facility for clients aged 18 to 59 level 4i/6, the current census is 6. The physical plant was inspected including but not limited to the kitchen, common areas, client bedrooms, client bathrooms, the storage areas, the exteriors, and evacuation routes. the Facility was clean, and traffic areas are well lit and unobstructed. Kitchen has adquate storage for sharps, medication, and toxics. Food supply is adequate for 2days perishable and 7 days nonperishable and 3 days emergency foods. Common areas are well equipped for actives. Bedrooms have required furniture's and furnishings, lacks bed bug encasements. Administrator was open to getting them. Bathrooms have hardware in good repair, missing a shower mat in one bathroom. Administrator was open to getting one. The exteriors are clean and have adequate space. Evacuation route exterior gate is secured with a bit of cord and dragging against the ground, the administrator will ajust/fix that gate such that it can swing freely and self close. posters are of correct dimensions, fire extinguishers are last dated 7/29/25. Administrator file contained present and up-date- surety bond, liability insurance, facility sketch. 5 of 6 client files were reviewed. they contained present and up-to-date: fingerprinting clearance, first aid, and trainings. 5 of 12 staff files were reviewed. they contained present and up-to-date, 602s, IPPs, preapraisals for health and mental health, P+I, safe gaurded property, and signed admission agreements. 0 interviews for clients, they were nonverbal, seemed happy, clean, well fed. 2 staff were interviewed. Exit interview was conducted. a copy of the report was read and left with the staff.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

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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