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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701520
Report Date: 01/13/2025
Date Signed: 01/13/2025 11:12:19 AM

Document Has Been Signed on 01/13/2025 11:12 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PERIDOT RESIDENCEFACILITY NUMBER:
392701520
ADMINISTRATOR/
DIRECTOR:		DE LARA, CECILFACILITY TYPE:
740
ADDRESS:15310 ROSELLA WAYTELEPHONE:
(209) 451-1645
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 8CENSUS: 0DATE:
01/13/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Cecil De Lara TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 01/13/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to this facility to conducted to a Pre-Licensing visit. LPA Pascua met with Applicant, Cecil De Lara and explained the purpose of the visit. The purpose of this visit was to conduct a pre-licensing visit.
This facility intends to hold 8 non-ambulatory residents. This facility also will hold a dementia plan on file and a hospice waiver for 6 residents.

Current census was 0. A brief interview with Applicant, Cecil De Lara.
The perspective Facility Designated Administrator (FDA), Cecil De Lara has a current RCFE Administrator certificate #6066497740 and expires on 03/21/2025.
A tour of the facility was conducted.
A fire extinguisher was identified in the kitchen area and was serviced by Armor Fire Co and is valid until 07/19/2025. Smoke Detectors and carbon monoxide were observed throughout the facility and was observed to be in working condition.
A tour of the kitchen area was conducted. Toxins, cleaning supplies, and knives were observed to be locked and made inaccessible. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supplies at this time.
A tour of the living area was conducted. Furniture and furnishing were observed to be in good repair and could meet resident needs.
A tour of the backyard was conducted. Gate and perimeter fence was in stable condition. This facility has one exit gate in which was self closing and self latching.
A tour of the 4 resident bedrooms were conducted. Bedroom #1 has a resident bathroom connected to the bedroom. All bedrooms would house 2 non-ambulatory residents at any time. All bedrooms were observed to have a sufficient amount of furniture and furnishings to meet resident needs.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PERIDOT RESIDENCE
FACILITY NUMBER: 392701520
VISIT DATE: 01/13/2025
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A tour of the resident bathrooms were conducted. Bathroom #1 had a linen closet. LPA observed a sufficient amount of linens to meet resident needs. Hot water was taken in both bathrooms to ensure hot water temperature was within the required range. Grab bars and non-skid mats were also observed and were in good repair at this time.
A tour of the laundry room was conducted. Washer and dryer were identified. Laundry detergent was observed to be locked and made inaccessible.
This facility will be housing resident medication in a locked closet next to the laundry room. First aid kit was present and had the required components.
A tour of the garage was conducted. An additional freezer and refrigerator unit were identified. Additional facility supplies were also identified.

Based on the observations made during this visit, there are no deficiencies observed during this Pre-Licensing visit. This applicant has passed this pre-licensing visit.

This applicant has already completed Comp I and Comp II.
A review of Comp III was conducted.

An exit interview was conducted and a copy of this report was provided to the Applicant at the end of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC809 (FAS) - (06/04)
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