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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 095002919
Report Date: 07/27/2022
Date Signed: 07/27/2022 10:29:59 AM

Document Has Been Signed on 07/27/2022 10:29 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:PLEASANT CARE HOMEFACILITY NUMBER:
095002919
ADMINISTRATOR:SEPULVEDA, LINAFACILITY TYPE:
740
ADDRESS:4880 RIVENDALE RD.TELEPHONE:
(530) 647-2899
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY: 6CENSUS: 0DATE:
07/27/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lina SepulvedaTIME COMPLETED:
10:45 AM
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On 07/27/22, at 9:30am , Licensing Program Analyst (LPA) Talwinder Bains met with applicant, Lina Sepulveda to conduct a Pre- Licensing visit. LPA followed current Covid precautions- self screened, hand sanitized and surgical mask worn.

The facility has a fire clearance for 6 non ambulatory residents. Applicant holds a current administrator certificate (#6023057740 with expiration date 12/06/2022 ).



LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are 6 bedrooms for residents, 1 staff break room and 3 bathrooms .LPA observed facility to be properly furnished, including appropriate bedding and lighting in bedrooms. Bathrooms were in sanitary condition and properly maintained.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home to be operational. Fire extinguisher and first aid kit are maintained and ready for emergency use. LPA inspected outside area and backyard area and found it clutter free.

Pre-licensing passed and Component III was waived because Lina was licensee for RCFE for this location in the past. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application.

A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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