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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803707
Report Date: 03/20/2023
Date Signed: 03/20/2023 02:32:05 PM

Document Has Been Signed on 03/20/2023 02:32 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: 3DATE:
03/20/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Caregiver, Shella Pastore
Administrator Libia Cruz-Leon		TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced for the purpose of conducting a Annual Continuation. LPA was greeted at the door by Caregiver, Shella Pastore, and was granted access into the facility.

During this Case Management-Annual Continuation, LPA interviewed staff and residents in care. LPA reviewed staff and resident files during this Case Management-Annual Continuation. LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610E)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents
Copy of Administrator Certificate

No deficiencies were 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: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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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