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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202962
Report Date: 11/30/2023
Date Signed: 11/30/2023 02:39:58 PM

Document Has Been Signed on 11/30/2023 02:39 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:CABRERA'S GUEST HOME 2FACILITY NUMBER:
397202962
ADMINISTRATOR:ELISEO CABRERAFACILITY TYPE:
735
ADDRESS:1495 LAGUNA CIRCLETELEPHONE:
(209) 598-7588
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 4DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Eliseo Cabrera TIME COMPLETED:
02:45 PM
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On 11/30/2023 at 11:15 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. No one was at the home upon arrival. LPA Lee was approached by designated staff, Digna Cabrera via the ring camera. LPA Lee introduced herself and explained the purposed of being at the home. LPA Lee explained that LPA Lee from with Community Care Licensing,the to conduct an annual inspection. Designated staff arrived approximately 30 minutes later. Administrator, Eliseo Cabrerra arrived approximately 10 minutes later and joined the visit. Both Digna and Eliseo assisted with today’s visit. Administrator certificate # is 6020179735 and will expire on 10/07/2024. The current census is 4.

This facility is a single story building licensed to serve six (6) clients and may have up to 3 non-ambulatory clients. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 115.7 degrees Fahrenheit in client bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in in the common area and was last serviced on 02/06/2023. The last fire drill was conducted on 11/01/2023. LPA Lee observed the facility has a has a public telephone in the common room and the kitchen. The facility has the required posters posted. Facility thermostat observed at 69 degrees Fahrenheit. LPA Lee observed toxins located in laundry and it was kept locked and inaccessible to clients. LPA Lee observed sharp knives kept locked and inaccessible to clients. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients.
Continued LIC 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: CABRERA'S GUEST HOME 2
FACILITY NUMBER: 397202962
VISIT DATE: 11/30/2023
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LPA Lee observed activities in the common area made available to clients at this time. LPA Lee reviewed and compared 4 out of 4 client medications and medication administration record (MAR) log and it was complete. The first aid kit was checked and contained all the required components. LPA Lee requested client and staff files for review. LPA Lee reviewed 4 out of 4 client files and 5 out of 5 staff files and they were complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents were given to LPA during today's visit.
(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance/Surety Bond

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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