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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804082
Report Date: 07/26/2022
Date Signed: 07/26/2022 12:49:05 PM

Document Has Been Signed on 07/26/2022 12:49 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:RUBY HOMEFACILITY NUMBER:
486804082
ADMINISTRATOR:BUNYI, LEONILAFACILITY TYPE:
740
ADDRESS:1679 TUCSON CIRCLETELEPHONE:
(707) 759-5173
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 5CENSUS: 0DATE:
07/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Leonila Bunyi, applicantTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Walters conducted a pre-licensing inspection and was greeted by Applicants, Cynthia Dinglasan and Leonila Bunyi. Leonila Bunyi will be the Administrator (Administrator Certificate 6020104740 exp 10/20/2022) once the facility has been approved for licensure. This pre-licensing inspection is being conducted as an initial facility application.

This facility is a single story home, with 4 bedrooms, 2 bathrooms, Living room, dinning room, family room, activity room, and kitchen. The Suisun City Fire Department granted this facility a fire clearance on 5/27/22 for 5 non-ambulatory residents no bedridden residents are to be permitted. There are currently 0 residents in care. LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Fire extinguisher was charged and current. Emergency Lights, Smoke detectors and carbon monoxide detectors were present. they were last tested by the fire department on 5/27/22. Exits were observed to be unobstructed. The hot water temperature measured at 106 & 107, in faucets used by residents. The Applicant has submitted their emergency disaster plan, that includes at least 2 emergency shelter locations. LPA observed that the facility had a current edition first aid kit, with all components that are required. The fireplace was appropriately screened.

Continued on 809 C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: RUBY HOME
FACILITY NUMBER: 486804082
VISIT DATE: 07/26/2022
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Bedrooms were furnished as required per regulation. Bathrooms were stocked with hand washing supplies and paper towels. There were grab bars and non-skid mats for residents safety. Signs were posted to encourage proper hand washing techniques. There was a sufficient supply of cleaning supplies, hygiene products, linen and personal protective equipment available for residents. Toxins will be stored in a locked cabinet in the garage and under the sink. Sharps are locked and secured, using a magnetic lock. There was a sufficient amount of food and emergency water as required per regulation. Facility has an activity room with activities available for residents such as bingo, badminton, wood painting etc.. for residents leisure. The applicant has submitted an infection control plan. LPA observed the following infection control procedures in place: visitor sign in area, hand sanitizer station, trash cans with lids to prevent airborne illness and signs posted to promote social distancing. The backyard was sufficient in size and easily accessible for residents.

Applicant will provide LPA with a copy of the liability insurance once the facility is licensed.

LPA conducted a COMP III with applicant some of the following items were discussed: Administrator Qualifications, Reporting Requirements, Maintenance and Operation, Personal Accommodations, Criminal Background clearance, Acceptance and Retention, Restricted and Prohibited Health Care Conditions.

This pre-licensing is complete. LPA will submit the pre-licensing reports to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. A copy of the report was given to the Applicant.


SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC809 (FAS) - (06/04)
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