486803077-4-3-2025-21-AS-JNAA-DFDQDG-20250403120444

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803077
Report Date: 04/03/2025
Date Signed: 04/03/2025 12:04:51 PM

Document Has Been Signed on 04/03/2025 12:04 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:	VICTORPAZ FARMHOUSE		FACILITY NUMBER:	486803077
ADMINISTRATOR/ DIRECTOR:	GOMEZ, ANNALEE		FACILITY TYPE:	740
ADDRESS:	506 KINGS WAY		TELEPHONE:	(707) 439-3757
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY: 6		CENSUS: 6	DATE:	04/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Licensee		TIME VISIT/ INSPECTION COMPLETED:	12:05 PM

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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Required 1-Year Annual Inspection. There were 6 residents and 2 staff on site at the time of inspection. Administrator was out of town at the time of inspection, however staff were able to reach by phone. Licensee Melissa Gomez arrived shortly..

When LPA arrived at the facility they were greeted by 2 carestaff. There were 6 residents in care. LPA toured the facility with staff and found the facility to be clean and comfortable. Signs were posted appropriately informing the use of oxygen. Bathrooms were equipped with grab bars and non-skid rugs. Paper towels and antibacterial soap were also available in bathrooms used by residents and staff. All residents' rooms were furnished per regulation. Medications are securely stored in a locked medication cart and each resident has a 30-day supply of medications. Cleaning products were not accessible to residents in care.

Kitchen was clean and orderly and there were perishable and non-perishable food stores as required per Title 22. Sharps were locked and inaccessible to residents. The living room had reclining chairs for the comfort of each resident while watching television, listening to music or partaking in activities together. The backyard includes a lovely covered patio for residents to enjoy the warm weather under shelter from the sun, with lots of accessible gardening activities.

Staff and resident records were complete and within regulation. Fire clearance is for three (3) non-ambulatory and three (3) bedbound. There were 3 fire extinguishers, last charged and inspected on 6/20/2024; fully charged. There were two (2) carbon monoxide detectors, which were tested and operational. There were seven (7) smoke detectors, which are tested monthly. Last fire drill was conducted 3/30/25.

LPA requested: new Facility Sketch to include new structures and driveways on property, updated LIC 500 and proof of liability insurance.

There were no deficiencies found at the time of inspection. No citations cited during today's visit.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Jill Nakagawa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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