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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803988
Report Date: 12/08/2022
Date Signed: 12/08/2022 03:31:38 PM

Document Has Been Signed on 12/08/2022 03:31 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:
12/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Desiree Rodriguez, Program Manager TIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection and investigation regarding unrelated incidents on 11/21/22 and 11/29/22.

LPA inspected the facility and found it to be clean and well-organized. The kitchen was well-stocked and residents had access to snacks, coffee and juices 24/7.

LPA requested documentation, interviewed staff and made observations.

Incidents were discussed with staff and Program Manager, who feel they were isolated incidents. Changes have been made regarding supervising residents and phone use (without infringing on their personal rights) but making sure residents are respecting the other residents in the area.

There were no deficiencies observed at the time of inspection.

No citations were given.

Exit interview conducted with Desiree Rodriguez, Program Manager.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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