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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803988
Report Date: 06/02/2022
Date Signed: 06/02/2022 02:49:02 PM

Document Has Been Signed on 06/02/2022 02:49 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 WESTFACILITY NUMBER:
576803988
ADMINISTRATOR:SALAZAR, MARITZAFACILITY TYPE:
735
ADDRESS:607 11TH STREETTELEPHONE:
(530) 758-7574
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 15CENSUS: 14DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Maritza Salazar, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator Maritza Salazar. 14 Clients were present at the facility.

LPA arrived at the facility on 6/2/22 at approximately 1:40 PM. There were postings on the front door requiring the wearing of face masks and screening for Covid-19 symptoms. Inside the front door a small table was set up with a binder to put all screening information for visitors, including the screening questions and temperature readings. There was hand sanitizer and masks for visitors use. During facility tour with Administrator Maritza Salazar; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Clients' bedrooms, common areas, kitchen & food storage areas were inspected. 3 Fire Extinguisher were found to be fully charged with a date of 6/20/21. Carbon monoxide detectors were tested and observed to be operational and there is a hard-wired fire system, last inspected on 07/27/21. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in the locked staff room. Sharps are stored in a lockable drawer in the kitchen, inaccessible to clients. There was a supply of hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Medications are stored and locked in Medication Room.

Since the last inspection the front and back yards have been re-landscaped, including walkways, picnic tables and shade structures for the residents' use.

No deficiencies were found during this inspection. No citations issued.

Exit interview conducted with Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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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