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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003040
Report Date: 09/01/2021
Date Signed: 09/01/2021 10:22:56 AM

Document Has Been Signed on 09/01/2021 10:22 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LITO GASPAR'S CARE HOMEFACILITY NUMBER:
347003040
ADMINISTRATOR:GASPAR, EMERITOFACILITY TYPE:
735
ADDRESS:8360 NIGHTFALL WAYTELEPHONE:
(916) 395-3238
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 6DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Emerito GasparTIME COMPLETED:
10:30 AM
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On 9-1-21 Licensing Program Analyst (LPA) Tirzah Hubbard and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced to conduct a Required – 1 Year inspection. LPA met with Administrator and Licensee Emerito Gaspar, and stated the purpose of today’s visit. LPA and LPM were allowed entry into the facility that is licensed to serve a total capacity of 6 clients. LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents. All required furniture were observed. LPA observed residents engaging in activity, wearing a mask and practicing social distancing.
Census: 6
Staff: 3
There are no recent COVID-19 positive results at this time. LPA toured bedroom 1, bedroom, 2, and bedroom 3. LPA toured the backyard, kitchen area, dining area, and garage.
All required COVID measures were observed. All bedrooms contained a dresser, bed, and night stand. The flooring of the facility has been replaced. LPA observed the thermostat 75*F temperature inside the facility hallway was measured at 71 *F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 108 *F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications locked and inaccessible to clients. LPA observed 3 of 3 medications counted properly labeled and stored, matching medication administration records (MAR).The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution. LPA observed a pull alarm system, fire extinguisher(s) due December 10, 2021, smoke and carbon monoxide detectors, central heating and air in the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: LITO GASPAR'S CARE HOME
FACILITY NUMBER: 347003040
VISIT DATE: 09/01/2021
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LPA observed there were food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times.

LPA observed the backyard area in good condition. LPA observed S1 cooking lunch for the residents in the garage area.

Mitigation Plan was submitted and approved.

Upon a file review the following items were discussed to be submitted with any changes annually:

Criminal Record Clearances LIC536
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Qualifications of Administrator/Facility Manager- Administrator certificate
Emergency Disaster Plan LIC610D - Update to ensure there is a location site outside of Sacramento for residents to evacuate to..


Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, there were no deficiencies cited during this visit. Exit interview held and a copy of report was given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC809 (FAS) - (06/04)
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