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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803706
Report Date: 06/02/2022
Date Signed: 06/03/2022 08:56:03 AM

Document Has Been Signed on 06/03/2022 08:56 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Shella Mae Pastor - staffTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff Shella Mae Pastor. There were 4 residents with 1 under hospice at this facility. Facility has activities planned for residents during the day.

LPA arrived at the facility and had her temperature checked and logged into a log. During facility tour on 6/2/2022 with staff; 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 8/2021 at the time of the visit. Sample test of Smoke Detectors & Carbon monoxide detector were found to be operational during this 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 garage. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings. Disaster Drills have been conducted every two months with the last one on 4/12/2022.

Continued LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LOMAS HOME
FACILITY NUMBER: 216803706
VISIT DATE: 06/02/2022
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Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at entrance and residents' bathrooms. Facility has hand sanitizer, masks, and other items available for visitors at entrance door inside the garage. Staff before coming into work have temperature checked. Facility has PPE supply stored in garage area and outside shed. There has been new staff hired and no new resident’s admitted since COVID. Residents’ medications are stored and locked in dining room closet. Facility has a 30-day supply of medication for clients. Residents are not 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. In addition, facility has a designated area for visitors which are being allowed. Residents have also available virtual and telephone calls when contacting with family members and others. Staff stated have had all PPE training required and N-95 fit testing for staff on file.

There were no deficiencies cited at this time.

Department is requesting facility to submit the following update documents by 6/9/2022:

LIC 308 Designated
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Certificate of Liability Insurance
Copy of Administrator Certificate
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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