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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803985
Report Date: 07/15/2024
Date Signed: 07/15/2024 04:13:17 PM

Document Has Been Signed on 07/15/2024 04:13 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/
DIRECTOR:
SALAZAR, MARITZAFACILITY TYPE:
735
ADDRESS:1214 E. 8TH STREETTELEPHONE:
(530) 758-7574
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 13CENSUS: 11DATE:
07/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Maritza Salazar, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Inspection at this facility and met with Administrator Maritza Salazar There were 11 clients residing at the facility. One (1) staff member was present in addition to the Administrator at the facility at the time of inspection.

LPA Nakagawa toured the facility and found it to be clean and at a comfortable temperature with all exits free from obstruction. Clients' bedrooms, common areas, kitchen & food storage areas were inspected. Three (3) Fire extinguishers were found to be serviced on 06/11/2024 and fully charged. There were two (2) carbon monoxide detectors that were tested and found to be operational. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerators were properly stored as per regulation on this day at the time of the visit. Toxins are stored and locked in cabinets under the kitchen sink and the office. Dangerous items were stored inaccessible to clients in the office and sharps are locked in a kitchen drawer. There was a supply of hygiene products and paper products available for clients. Water temperature was 117 degrees F; within regulation. Facility has an activities program several days a week. The facility's front and back yards provide a lovely tranquil spot for residents to enjoy, with plenty of shaded seating. Clients stated they enjoy the family atmosphere that the facility provides.

A sample of staff and client files were reviewed and found to be complete.

There were no deficiencies cited during today's visit.
Exit interview conducted with Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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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