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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486804082
Report Date:
09/26/2023
Date Signed:
09/26/2023 03:12:24 PM
Document Has Been Signed on
09/26/2023 03:12 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 HOME
FACILITY NUMBER:
486804082
ADMINISTRATOR:
BUNYI, LEONILA
FACILITY TYPE:
740
ADDRESS:
1679 TUCSON CIRCLE
TELEPHONE:
(707) 759-5173
CITY:
SUISUN CITY
STATE:
CA
ZIP CODE:
94585
CAPACITY:
5
CENSUS:
5
DATE:
09/26/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:45 PM
MET WITH:
Leonila Bunyi, Administrator
TIME COMPLETED:
03:20 PM
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection and check on the care plan of resident R1. LPA found the facility to be clean and organized. All the residents' rooms were clean and arranged for the comfort of the residents.
R1 was alert and resting comfortably in bed at the time of visit. R1 demonstrated that they were able to change position independently. Administrator has set up a day bed in the living room for R1 to use during the day so that R1 can participate in activities and socialize with the other residents and staff throughout the day during R1's convalescence.
There were no deficiencies found at the time of inspection.
No citations issued.
SUPERVISORS NAME
:
Kimberley Mota
LICENSING EVALUATOR NAME
:
Jill Nakagawa
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/26/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/26/2023
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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