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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701527
Report Date: 02/12/2025
Date Signed: 02/12/2025 03:19:02 PM

Document Has Been Signed on 02/12/2025 03:19 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CABRERA HOMECAREFACILITY NUMBER:
342701527
ADMINISTRATOR/
DIRECTOR:
DEJARESCO, DEANE J.FACILITY TYPE:
740
ADDRESS:4405 BELCREST WAYTELEPHONE:
(408) 561-4475
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: DATE:
02/12/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:07 PM
MET WITH:Mitzi Cabrera, Albert Cabrera and Deane dejarescoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Holly Williams arrived announced to conduct a pre-licensing inspection on 2/12/25. LPA Williams met with applicant Mitzi and Albert Cabrera and explained the purpose of the visit.

LPA Williams conducted a presentation of Component III for Residential Care Facilities for the Elderly (RCFE). LPA Williams reviewed pre-made resident files, and other application documents. LPA Williams toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents in care. LPA Williams observed rooms to have required furniture. The temperature inside the building was observed to be at 72 degrees Fahrenheit which is within the required range of 68-85 Fahrenheit. The hot water temperature was measured at 106.8 degrees Fahrenheit which is within the required range of 105-120*F.

The facility has no staff room. The employee's at the facility that work the night shift will be awake staff. According to record review, the plan of operation and the LIC500 state that the night staff members will be awake staff members.

LPA Williams observed the centrally stored medications area to be locked and inaccessible to residents. LPA Williams observed the fire extinguisher(s) and first aid kits were up to date. LPA Williams observed smoke and carbon monoxide detector(s) were in good repair.

Based on a review of this property during this Pre-licensing visit, it was determined that the applicant was found to be in compliance at this time. Applicant has completed Component III. LPA Williams will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

An exit interview was held and a copy of the report was provided to Mitzi Cabrera and Albert Cabrera.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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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