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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804094
Report Date: 12/05/2024
Date Signed: 12/05/2024 02:29:00 PM

Document Has Been Signed on 12/05/2024 02:29 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VILMA'S HOMEFACILITY NUMBER:
486804094
ADMINISTRATOR/
DIRECTOR:
NICOLAS, JETHROFACILITY TYPE:
740
ADDRESS:2925 GULF DR.TELEPHONE:
(650) 745-5080
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Nina German, Co- AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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12/05/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently four (4) residents in care. Facility approved/cleared for four (4) non-ambulatory, and hospice waiver for two (2).
At approximately 12:30pm, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled.
Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available for residents in care. LPA observed a daily schedule of activities. Water temperature in sinks accessible to residents in care were measured at 115.1 and 111.3 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 02/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to residents were located in the garage, locked drawer in kitchen, under the kitchen sink and were found to be secured. Facility has extra PPE located in the garage. Facility conducts monthly emergency disaster drills. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.
LPA conducted a review of four (4) resident records. All records had the required documentation. LPA conducted review of four (4) staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC309- Administrative Organization
Copy of Updated Liability Insurance

Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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