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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004556
Report Date: 05/20/2022
Date Signed: 05/24/2022 02:12:06 PM

Document Has Been Signed on 05/24/2022 02:12 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CASA DE LUZFACILITY NUMBER:
507004556
ADMINISTRATOR:MARIA L. ANDRADEFACILITY TYPE:
740
ADDRESS:3509 SCENIC DRTELEPHONE:
(209) 578-3077
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Johanna WestTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua conducted an unannounced Annual on 05/20/2022. LPAs met with the Facility Designated Administrator, Johanna West. There was one staff member present at this time, Tammy Hughes. This facility does not have a dementia program or hospice waivers.
Current capacity was full at 6.
A tour of this facility was conducted.
The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected and was valid until 06/01/2022.
The kitchen area was toured. LPAs observed a sufficient seven days of non-perishable foods as well as two days worth of perishable food supplies in the main kitchen. Soap, cleaning supplies, and knives were locked. Additional perishable and non-perishable food supplies were identified in the garage.
LPAs observed a locked centralized stored medication cabinet. The LPAs reviewed medication dispensing logs. First Aid Kit was present and contained all of the required components.
A tour the bedrooms was conducted.
Resident furniture was observed to be sufficient to meet their needs at this time.
A tour of the resident bathrooms was conducted. No soap or cleaning supplies were stored under the sinks. Hot water temperature was within the required range of 105-120 degrees. Grab bars were present and stable.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
A tour of the exterior physical plant was conducted. Perimeter fence, side gates, and exits was inspected.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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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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: CASA DE LUZ
FACILITY NUMBER: 507004556
VISIT DATE: 05/20/2022
NARRATIVE
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The following forms and documents were requested to be updated and submitted into CCL:
-LIC 308

-LIC 309

-LIC 400

-LIC 402

-LIC 500

-LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

Appeal rights were printed and a copy was given to the facility designated Administrator.

Exit Interview.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/24/2022 02:12 PM - It Cannot Be Edited


Created By: Arielle Pascua On 05/20/2022 at 12:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CASA DE LUZ
FACILITY NUMBER: 507004556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above since the wooden patio area was in disrepair with loose boards which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Administrator states to work with maintanence and owners to replace the wooden patio area. Administrator will plan to send POC to LPA by 05/27/2022
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2022 02:12 PM - It Cannot Be Edited


Created By: Arielle Pascua On 05/20/2022 at 12:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CASA DE LUZ
FACILITY NUMBER: 507004556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87212(b)(2)(G)
(b) The plan shall be subject to review by the Department and shall include:

(2) Plan for evacuation including:

(G) Means of contacting local agencies such as fire department, law enforcement agencies, civil defense and other disaster authorities.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above since the side exit did not allow access from the exterior in case of emergency and disaster, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Administrator states to work with maintanence in order to relatch the side exit. Administrator will plan to provide POC to LPA by 05/27/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022


LIC809 (FAS) - (06/04)
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