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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803985
Report Date: 11/15/2022
Date Signed: 11/15/2022 04:11:17 PM

Document Has Been Signed on 11/15/2022 04:11 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PINE TREE GARDENS EASTFACILITY NUMBER:
576803985
ADMINISTRATOR:SALAZAR, MARITZAFACILITY TYPE:
735
ADDRESS:1214 E. 8TH STREETTELEPHONE:
(530) 758-7574
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 13CENSUS: 13DATE:
11/15/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Dedre Rodriguez, Program ManagerTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Post-Licensing inspection on 11/15/2022 at approximately 3:00 PM. LPA is conducting visit with Dedre Rodriguez (DR), Program Manager. There are currently 13 residents in care. There were 3 staff on site at the time of inspection.

The amount of fresh and nonperishable foods appeared to be within regulation. Medications and toxins are locked in Staff Room. Sharps and Chemicals are also locked in kitchen. Bathrooms were equipped with necessary grab bars and non-slip floors/mats and appeared to have sufficient hygiene products. LPA observed that resident rooms were furnished per regulations. Fire extinguishers were last inspected 6/23/22 (2 extinguishers) and 2 Carbon Monoxide Detectors were observed and operational.

LPA observed required postings regarding COVID-19 precautions throughout the facility and required visitation postings. Facility is screening visitors at the front door. LPA observed a sufficient supply of PPE equipment. The facility staff was observed wearing masks during the tour of main entrance, doors, common areas, dining room and kitchen area. LPA reviewed documents in 2 resident files. Program Manager stated disaster drills are conducted quarterly. Administrator's Certificate 6027846735 expires 07/02/24.

No deficiencies cited during today's inspection.
Exit interview conducted with Program Manager,
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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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