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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001696
Report Date: 03/27/2024
Date Signed: 03/27/2024 02:19:03 PM

Document Has Been Signed on 03/27/2024 02:19 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LA HONDA GUEST HOMEFACILITY NUMBER:
347001696
ADMINISTRATOR:TORRES, MARGARITAFACILITY TYPE:
740
ADDRESS:3940 LA HONDA WAYTELEPHONE:
(916) 944-8909
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
03/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Neal TorresTIME COMPLETED:
01:00 PM
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On 3/27/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident LPA observed from incomplete annual inspection on 3/14/2024. LPA met with Licensee, Neal Torres, and explained the purpose of the visit.

LPA was informed that R1 was sent to the emergency room as there was an error on R1's oxygen machine. Licensee stated the machine has stated oxygen level at 88, but once fire department arrived, their machine was reading level at 96. Licensee continued that when emergency medical services arrived, their machine was reading oxygen level another inconsistent level. Licensee stated R1 was transported with emergency medical services to the emergency room to ensure their health and safety. LPA was informed R1 now has a new oxygen machine.

LPA and Licensee discussed submitting incident reports, LIC 624, in a timely manner as it is required. LPA provided Licensee a copy of Title 22, California Code Regulation 87211 Reporting Requirements.

No deficiencies cited.

Exit interview conducted and a copy of report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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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