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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804016
Report Date: 01/27/2025
Date Signed: 01/27/2025 05:27:13 PM

Document Has Been Signed on 01/27/2025 05:27 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:HER ONLY DAUGHTER SENIOR CARE HOMEFACILITY NUMBER:
486804016
ADMINISTRATOR/
DIRECTOR:		BOOKER, JANAIFACILITY TYPE:
740
ADDRESS:130 PURDUE DR.TELEPHONE:
(707) 295-3200
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 5CENSUS: 0DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:39 PM
MET WITH:Administrator, Janai BookerTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
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On 1/27/2025 Licensing Program Analyst (LPA) Araceli Canela conducted an unannounced Annual Required – 1 yr. inspection and met with Administrator, Janai Booker. The facility currently has 0 residents in care.

LPA toured the home inside and out with Administrator, facility was found to be clean and at a comfortable temperature. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 1/2/2025.

All resident’s bedrooms have lighting & appropriate furnishings. Facility has appropriate bedding and linens available for resident use. Hot water measured between 105.0 and 120 degrees F which is within Title 22 regulations.

LPA requested Licensee to inform Community Care Licensing when they admit their first resident.

Licensee/Administrator to submit the below documents to LPA by 2/27/2025.


· LIC 500 Personnel Report-
· LIC 610E Emergency Disaster Plan if any changes

No deficiencies cited.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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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