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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803988
Report Date: 11/10/2022
Date Signed: 11/10/2022 02:53:46 PM

Document Has Been Signed on 11/10/2022 02:53 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: 15DATE:
11/10/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Desiree Rodriguez, House Manager on site and
Maritza Salazar (via phone)
TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Post-Licensing inspection on 11/10/2022 at approximately 1:30 PM. LPA is conducting visit with Desiree Rodriguez (DR), Program Manager and Maritza Salazar, Administrator, via phone. There are currently 15 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 were observed locked in medication room. Toxins were observed locked in a small restroom, accessible by staff only. 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 09/16/22 (1 extinguisher) 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 essential 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. LPA reviewed 2 staff records and found that staff had current First Aid/CPR training. House Manager stated disaster drills are conducted monthly. Administrator's Certificate 6027846735 expires 07/02/24.

No deficiencies cited during today's inspection.
Exit interview conducted with house manager, DR.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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