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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803707
Report Date: 04/03/2024
Date Signed: 04/03/2024 12:08:25 PM

Document Has Been Signed on 04/03/2024 12:08 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:LUNA'S HOMEFACILITY NUMBER:
216803707
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:
CRUZ-LEON, LIBIAFACILITY TYPE:
740
ADDRESS:1027 LAS PAVADAS AVENUETELEPHONE:
(650) 387-9488
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 4CENSUS: 3DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator, Shella PastorTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:15AM to conduct an Annual Required inspection and was greeted by staff. LPA and staff discussed the purpose of the visit. Back up Administrator, Shella Pastor arrived shortly after.

LPA and Administrator initiated a tour of the facility around 09:45 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 112 and 113 degrees F which is within the range of 105 to 120 degrees F allowed per regulation.

Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is stored in hallway closet. Personal Protective Equipment is stored in the garage.


Fire extinguishers were last serviced May 17, 2023. Facility has combination smoke and carbon monoxide detectors located throughout the facility that were tested and operational during inspection. Facility is equipped with fire doors on all doors. Most recent fire/disaster drill was conducted 01/14/2024. Client cash resources were reviewed. Facility was over the limit listed on their LIC400 (Affidavit Regarding Client Cash Resources). LPA and Administrator discussed that they must update their LIC400 and their Surety Bond in order to handle a larger sum of cash.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LUNA'S HOME
FACILITY NUMBER: 216803707
VISIT DATE: 04/03/2024
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Continued from LIC809

Five staff files and three resident files were reviewed. Staff have required First Aid and CPR certificates. Medications and medication records were reviewed. Administrator Certificate for Administrator, Shella Pastor (6060239740) is up to date and expires 07/07/2025.

No deficiencies cited during inspection.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on forms confirms receipt of documents.

LPA is requesting the following documents to be submitted to Community Care Licensing by 05/03/2024:

LIC 500 Personnel Report

LIC 9020 Resident Roster
LIC 308 Designation of facility responsibility
Updated LIC 400 Affidavit Regarding Client Cash Resources
Updated Surety Bond
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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