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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700499
Report Date: 05/04/2022
Date Signed: 05/04/2022 04:35:17 PM

Document Has Been Signed on 05/04/2022 04:35 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CASA DE STELLA LLCFACILITY NUMBER:
502700499
ADMINISTRATOR:HERNANDEZ, STELLAFACILITY TYPE:
735
ADDRESS:2210 CLOCK TOWER CTTELEPHONE:
(209) 869-4571
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 5CENSUS: 5DATE:
05/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Stella HernandezTIME COMPLETED:
04:30 PM
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On 5/4/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year visit. LPA Jensen met with Licensee Stella Hernandez and explained the purpose of today's visit.

The facility is a two story building with 5 bedrooms. There is one central entry point. Upon arrival LPA Jensen was greeted by the facility manager, was temperature screened as a precautionary measure for COVID-19 and had ID checked. LPA Jensen was allowed entrance into the facility. At the entrance inside the facility, signage for personal rights, COVID precautions, house rules and Administrator certificates are posted. The Administrator certificate # 6049293735 for Stella Hernandez expires on 5/26/23. The LPA observed the entrance to have sign in sheets, masks and hand sanitizer. LPA Jensen toured the facility including but not limited to the activity room, dining room, kitchen, two bathrooms, resident bedroom, grounds and garage. A 30 day supply of PPE was observed. Visitor, staff and resident temperature logs were observed to be maintained, accurate and up to date. A first aid kit was available and complete. All toxins, medications and sharp objects are kept locked and inaccessible to residents. The facility had a two day supply of perishable food and a 7 day supply of non perishable food. An emergency supply of food and water was observed. A log is maintained for water temperature, refrigerator temperature and freezer temperature with checks occurring twice daily. The emergency plan was complete and posted in a prominent location. The fire extinguishers were last serviced on 5/1/22 and are in compliance. The carbon monoxide detectors were verified to be in good working order. The facility contained adequate lighting and furnishings for the comfort of the residents. The temperature of the facility was 73 degrees which falls within the required range of 68 degrees to 85 degrees. The facility was clean, sanitary and the grounds were well maintained. A bathroom cleaning log is maintained and cleaning and disinfecting is done twice daily. All exits were clear of obstruction. All staff are vaccinated and boosted and in compliance with public health orders.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Exit interview held, copy of report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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