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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803988
Report Date: 08/08/2023
Date Signed: 08/08/2023 04:57:10 PM

Document Has Been Signed on 08/08/2023 04:57 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:
08/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Desiree Rodriguez, House Manager and Maritza Salazar, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual inspection on 08/08/2023 at approximately 2:00 PM. LPA is conducting visit with Desiree Rodriguez (DR), House Manager and Maritza Salazar, Administrator. 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. Fire extinguishers were last inspected 6/26/2023 (2 extinguishers) and 2 Carbon Monoxide Detectors were observed and operational.
LPA reviewed 5 staff records and found that staff had current First Aid/CPR training. LPA also observed 5 resident records and found them to be complete. House Manager stated disaster drills are conducted monthly. Administrator's Certificate 6027846735 expires 07/02/24. Activities are facilitated 4 days a week with an activities director and other activities are provided as requested by the residents (such as arts and crafts or games, stationary bike).

No deficiencies cited during today's inspection.
Exit interview conducted with Maritza Salazar, Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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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