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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801443
Report Date: 01/03/2025
Date Signed: 01/03/2025 04:43:41 PM

Document Has Been Signed on 01/03/2025 04:43 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:MASONIC GUEST HOMEFACILITY NUMBER:
486801443
ADMINISTRATOR/
DIRECTOR:		LACAP, LEONIDAFACILITY TYPE:
740
ADDRESS:310 MASONIC DR.TELEPHONE:
(707) 554-1432
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 6DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Leni LacapTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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On 01/03/2025, Licensing Program Analyst (LPA) Araceli Canela arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Leonida Lacap and explained the purpose of the visit. This facility is a one story home, licensed for 6 non-ambulatory residents, of which one may receive Hospice services.

LPA Canela and administrator toured the facility together and facility was found at a comfortable temperature with all exits free from obstruction. Areas toured include but are not limited to five (5) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair, with the required grab bars. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored properly and the facility has the required (7) seven-day non-perishable and (2) day perishable supply of food.



First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged and was last serviced on 9/10/2024. Smoke detectors are all operational. No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 7/23/24, the facility has been conducting drills every 3 months. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities Planned for the residents and 3 of the residents attend day program . All required postings are displayed within facility.

Staff and resident files were reviewed. Medication is locked in a locked closet.


Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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: MASONIC GUEST HOME
FACILITY NUMBER: 486801443
VISIT DATE: 01/03/2025
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 Administrator certificate for, Leonida Lacap (cert #6006612740 exp.10/10/2025) is current.

LPA went over last visit in August and the facility had a current medical assessment for R1, the items in the backyard were removed and no citations were issued.

Licensee/Administrator to submit the current following documents by 1/25/2025:

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of Liability Insurance

The facility is in compliance. No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report was emailed to administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
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