<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803706
Report Date: 07/01/2021
Date Signed: 07/01/2021 03:57:59 PM

Document Has Been Signed on 07/01/2021 03:57 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LOMAS HOMEFACILITY NUMBER:
216803706
ADMINISTRATOR:CRUZ-LEON, LIBIAFACILITY TYPE:
740
ADDRESS:472 ALAMEDA DE LA LOMATELEPHONE:
(415) 234-6378
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 4CENSUS: 4DATE:
07/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Director Libia Cruz-LeonTIME COMPLETED:
04:00 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
Licensing Program Analysts (LPAs) Fernandes-Goes & Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator/Licensee Libia Cruz-Leon. Residents were present at the facility due to COVID-19. Facility has 2 clients that day program has zoom activities, 2 clients do in home day program one on one zooms. Facility has puzzles and other activity plans for clients during the day.

During LPA’s Fernandes-Goes & Hansen facility tour on 7/1/2021 with administrator Cruz-Leon; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 07/2020 at the time of the visit. Smoke Detectors & Carbon monoxide detector was found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside the garage. Dangerous items (toxins & knives/sizers) were locked under kitchen sink inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Hot water temperature measured 105.9 degrees F, within acceptable regulations of 105 to 120 degrees F.

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in the family area cabinet and garage. Facility has not hired or admitted anyone new since COVID-19. Clients’ medications are stored and locked by the garage area. Facility has a 30-day supply of medication for clients. Clients aren’t wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit.

Continued on LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2021
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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: LOMAS HOME
FACILITY NUMBER: 216803706
VISIT DATE: 07/01/2021
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
26
27
28
29
30
31
32
Department is requesting a copy of:

Lic 400

Lic 402

facility Liability Insurance

Copy of Lease to be submitted to RO Rohnert Park by July 8, 2021.

There were no deficiencies cited at this time

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2