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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803251
Report Date: 07/07/2021
Date Signed: 07/07/2021 12:06:14 PM

Document Has Been Signed on 07/07/2021 12:06 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MASONIC GUEST HOME IIFACILITY NUMBER:
486803251
ADMINISTRATOR:LACAP, LEONIDAFACILITY TYPE:
740
ADDRESS:108 PINTO DRIVETELEPHONE:
(707) 644-3822
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 6DATE:
07/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Administrator, Leonida LacapTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Farhaan Sarangi arrived at Masonic Guest Home II for the purpose of conducting a Required 1-year inspection. LPA met with Administrator, Leonida Lacap and was granted access into the facility.

LPA toured the facility and found the facility was at comfortable temperature, free from obstructions. and was well lit. Hygiene products and linens were available and required bath mats and grab bars were observed. Water temperature in resident's bathrooms measured 112 degrees F which are within acceptable range of 105 to 120 degrees F. LPA observed detergent unlocked. Administrator locked the detergent. Technical Violation (LIC 9102) was noted. Knives are located in the locked medication cabinet in the dining area. Perishable and non-perishable foods were sufficient, with a 2 day supply of perishable foods, and a 7 day supply of non-perishable foods, as required. Medications were centrally stored and locked. Residents Responsible Parties handle their own cash resources. Fire extinguisher located in the kitchen was last inspected August 2020. Smoke detectors located throughout the facility and carbon monoxide detectors were tested and functional. Exit doors have auditory alert system.

In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA observed the Administrator not wearing a Face mask and no entry screening. Technical Violation was noted on a LIC 9102.



Licensee/Administrator to submit updates of the following documents: Evidence of Liability Insurance, Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Emergency Disaster Plan (LIC610E). No deficiencies were cited during this Required 1-year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Leonida Lacap.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2021
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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