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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803707
Report Date: 03/13/2023
Date Signed: 03/13/2023 03:16:07 PM

Document Has Been Signed on 03/13/2023 03:16 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:LUNA'S HOMEFACILITY NUMBER:
216803707
ADMINISTRATOR:CRUZ-LEON, LIBIAFACILITY TYPE:
740
ADDRESS:1027 LAS PAVADAS AVENUETELEPHONE:
(650) 387-9488
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 4CENSUS: 4DATE:
03/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Caregiver, Shella PastoreTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Caregiver, Shella Pastore, and was granted access into the facility.

LPA and Caregiver toured the facility. The facility was inspected and found to be clean and in good repair at the time of the inspection with all exits free from obstruction. Fire Extinguishers are dated for May 2022. Smoke detectors and carbon monoxide detectors were found to be operational at the time of the inspection. Hot water temperature measured at 110 degrees in 2 of 2 residents bathrooms. Hot water temperature is within acceptable range of 105-120 degrees. There was ample space for personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Resident records, personnel Records, medication will be locked on this level in separate cabinets, toxins are kept locked in the garage; facility has first aid kit which was inspected and found to be appropriate during the Required 1 year inspection inspection. Activities menu and food menu was available for viewing during the inspection. There was a sufficient supply of both perishable and non-perishable foods as outlined in Title 22 regulations. Special diets are in place for residents who require special diets. There is outdoor space for activities. Emergency Disaster plan was discussed in length with the Caregiver. LPA observed the Portable Emergency Generator in the backyard shed and accessible in case of an emergency and/or power outage occurs. Next Emergency Disaster drill is scheduled for March 18, 2023.

LPA discussed the infection control plan with the facility caregiver and advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

Annual Continuation is warranted. No deficiencies were observed or cited during this Required 1 year inspection. Exit interview was conducted and a copy of this report was signed and given to the Caregiver.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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