392701520-1-8-2026-27-AS-APAA-DQ5TWU-20260108140606

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701520
Report Date: 01/08/2026
Date Signed: 01/08/2026 02:06:54 PM

Document Has Been Signed on 01/08/2026 02:06 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:	PERIDOT RESIDENCE		FACILITY NUMBER:	392701520
ADMINISTRATOR/ DIRECTOR:	DE LARA, CECIL		FACILITY TYPE:	740
ADDRESS:	15310 ROSELLA WAY		TELEPHONE:	(209) 451-1645
CITY:	LATHROP	STATE: CA	ZIP CODE:	95330
CAPACITY: 8		CENSUS: 6	DATE:	01/08/2026
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:25 PM
MET WITH:	Mary Jane Del Mundo		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 01/08/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to this facility to conducted to an annual visit. LPA Pascua was greeted by Staff Member (SM), Cecilia Catbagan and explained the purpose of the visit. The purpose of the visit was for an annual visit. LPA Pascua was notified by Facility Designated Administrator (FDA), Cecil De Lara that she is currently not available to come to the facility and has Designated, Mary Jane Del Mundo as the Facility Designated Representative to continue the visit with LPA Pascua. There was one other staff member present, Marysan Murphy. 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 6. 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. LPA Pascua reviewed 6 resident files and 4 staff files. All files were current and up to date. A tour of the facility was conducted. A fire extinguisher was identified in the kitchen area and was serviced by Jorgenson Co and is valid until 01/02/2026. 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. Two sheds were identified.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/08/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PERIDOT RESIDENCE	FACILITY NUMBER: 392701520
	VISIT DATE: 01/08/2026

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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.
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.
A medication closet was identified, along with FDR Del Mundo. LPA Pascua reviewed and compared Medication Administration Records with Medication. LPA Pascua provided technical assistance regarding Medication Administration Records.
A tour of the garage was conducted. An additional freezer and refrigerator unit were identified. Additional facility supplies were also identified.

The following documents were requested to be submitted to the department:
-LIC 308
-LIC 400
-LIC 500
-LIC 610e

Technical assistance was provided for Section 87465(a)(4)
Based on the observations based during the visit, there are no deficiencies were observed or cited during this annual visit.

An exit interview was conducted and a copy of this report was provided to the Facility at the end of this visit.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/08/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

LIC809 (FAS) - (06/04)

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