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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803693
Report Date: 10/20/2023
Date Signed: 10/20/2023 03:30:09 PM

Document Has Been Signed on 10/20/2023 03:30 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:WAYNE HOMEFACILITY NUMBER:
486803693
ADMINISTRATOR:MONTECLAR, IRENEFACILITY TYPE:
740
ADDRESS:909 CALLE DEL CABALLOTELEPHONE:
(650) 703-1217
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 3DATE:
10/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:TIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Required – 1 year inspection at Wayne Home. LPA was welcomed by Facility Manager, Danica Ednalaga and was granted access into the facility. Administrator arrived later.

LPA began touring the facility with Facility Manager. LPA observed the hallway and passageways leading to exits were free of obstruction and facility temperature was comfortable. Hot water temperature measured within range of 105 degrees and 120 degrees F. Smoke and carbon monoxide detectors were tested and found to be operational during the inspection. Fire extinguishers last serviced/charged on July 26, 2023. Toxins were stored locked under the kitchen sink and in the laundry room. Sharp knives were observed to be locked in a kitchen drawer which is inaccessible to residents in care. Toilet and shower areas were clean and sanitary. Residents requiring special care have hoyer lifts installed in rooms. Ample supply of hygiene products were stored in a cabinet in the garage. Perishable and non-perishable food supply met the requirements for current census. Refrigerator and freezers were clean and food was stored properly. Medications centrally stored and locked in a cabinet located in the living room. Small locked refrigerator is used for medications requiring refrigeration located in the garage.

Licensee provides special activities for residents, including outings to Disneyland. Residents also attend Day Programs when available.

No deficiencies found at the time of inspection. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
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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