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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700499
Report Date: 06/24/2022
Date Signed: 06/24/2022 01:21:49 PM

Document Has Been Signed on 06/24/2022 01:21 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:
06/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to conduct a case management visit related to multiple incident reports received for resident 1 (R1). LPA Jensen met with Licensee Stella Hernandez.

LPA Jensen interviewed staff 1 (S1) and the Licensee. LPA Jensen reviewed resident file including IPP's, physician report upon intake, regional center 30 day assessment, SIR's and medical records. Licensee has been in regular contact with regional center case worker and has been providing updates to LPA Jensen via email. Licensee has communicated with LPA Jensen and the Regional Center the resident's need for a higher level of care due to a deterioration in R1's health.

LPA Jensen verified the regional center is actively seeking alternative placement to a facility better equipped to meet the resident's medical needs. LPA Jensen verified all reporting requirements have been met and in a time frame consistent to meet regulatory requirements.

The resident was given a 30 day eviction notice on 5/25/22 which was approved by CCLD. Due to the resident's recent hospitalizations the facility is holding a bed until 6/30.

As a result of today's visit no deficiencies were cited from the California Code of Regulations Title 22, Division 6.
An exit interview was conducted and a copy of this report was left with Licensee Stella Hernandez
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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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