<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803077
Report Date: 04/15/2024
Date Signed: 04/15/2024 01:39:20 PM

Document Has Been Signed on 04/15/2024 01:39 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:VICTORPAZ FARMHOUSEFACILITY NUMBER:
486803077
ADMINISTRATOR/
DIRECTOR:		GOMEZ, ANNALEEFACILITY TYPE:
740
ADDRESS:506 KINGS WAYTELEPHONE:
(707) 439-3757
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 6CENSUS: 6DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Annalee GomezTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Administrator Annalee Gomez.

This facility has a fire clearance for three non-ambulatory and three bedridden residents. There are six private resident rooms. There are several common areas. This facility has a hospice waiver for two. There is an ample supply of perishable and nonperishable food.

Several topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by April 30, 2024:
-LIC 500 facility personnel or staff schedule
-LIC 308 designation of administrative responsibility
-liability insurance.

Facility is in compliance.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1