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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803988
Report Date: 07/15/2024
Date Signed: 07/15/2024 02:22:51 PM

Document Has Been Signed on 07/15/2024 02:22 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/
DIRECTOR:
SALAZAR, MARITZAFACILITY TYPE:
735
ADDRESS:607 11TH STREETTELEPHONE:
(530) 758-7574
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 15CENSUS: 14DATE:
07/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Maritza Salazar, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual inspection on 07/15/2024 at approximately 11:45 AM. LPA is conducting visit with Maritza Salazar, Administrator. There are currently 14 residents in care. There were 2 staff in addition to the Administrator on site at the time of inspection.

The facility was clean and a comfortable temperature. The facility had just recently gotten a new air conditioning unit in one of the buildings. The other building had a new tankless water heater added. When LPA arrived many of the residents were sitting at the dining room table having lunch together. There was an ample supply of of fresh and nonperishable foods as required in Title 22 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 had soap and paper towels and were sufficiently supplied with other hygiene products. The facility has 2 fire extinguishers which were last inspected on 03/14/2024 and were fully charged. 2 carbon monoxide detectors were tested and operational at the time of inspection.The last disaster drill was conducted in June, 2024. The fire department conducted an inspection on 10/11/2023 and found no violations.
LPA spoke with 5 out of 14 clients, all of whom reported that the Administrator, Licensee and staff provided them with good care and food.
LPA reviewed records of 5 staff and 5 residents and found them to be complete.
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: 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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