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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804227
Report Date: 05/29/2024
Date Signed: 05/29/2024 12:27:22 PM

Document Has Been Signed on 05/29/2024 12:27 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:LIA RAMA HOME CAREFACILITY NUMBER:
486804227
ADMINISTRATOR/
DIRECTOR:		GANZON, CECILIAFACILITY TYPE:
740
ADDRESS:1718 SEVERUS DRIVETELEPHONE:
(707) 334-9242
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: DATE:
05/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Jill Nakagawa arrived announced at Lia Rama for the purpose of conducting a Pre-Licensing Inspection. LPA was greeted at the door by Licensee, Ruby Anne Alinio, and Administrator Cecilia Ganzon and was granted access into the facility. The facility is approved for 6 Non-Ambulatory Residents with a waiver for 2 hospice care. A dementia care plan was submitted. Administrator presented the LPA with the Administrators Certificate for Residential Care Facility for the Elderly (Standard Certificate #6020523740 with an expiration of 07/28/2024).

LPA and Licensee toured the one story facility, which was found to be clean, safe and sanitary with all exits free from obstruction. Fire Extinguisher was found to be fully charged and inspected 3/15/2024. All smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the Pre-Licensing inspection. Hot water temperature measured at 108.8 degrees in 2 of 2 clients bathrooms and is within Title 22 regulation. Sample food menu was observed on the refrigerator. Activities Menu was observed and activities (puzzles, games, Karaoke Machine, Radio, TV) was stored in the family room. LPA observed sufficient perishable and non-perishable foods located in the refrigerator and pantry. There was ample space for personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Sharps were locked in a kitchen drawer, inaccessible to residents. Resident records, personnel records will be locked in closet in living room. Medications will be locked in kitchen cabinet and inaccessible to clients in care. Hazardous items and toxins are kept locked in a family room cupboard and inaccessible to clients in care.
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SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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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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: LIA RAMA HOME CARE
FACILITY NUMBER: 486804227
VISIT DATE: 05/29/2024
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Continued from 809......

Facility has a first aid kit which was inspected and found to be complete with scissors and tweezers. There is an outdoor space for activities with a shaded area for clients in care. LPA observed a garden in the backyard that will be utilized for activities. Emergency Disaster plan was discussed with the Licensee.

Pre-licensing is complete and this facility has no corrections needed, no deficiencies.

Component III was conducted and questions regarding fingerprinting, reporting requirements were discussed. Exit interview was conducted, and a copy of this report was given to the Licensee. LPA will forward this report to LPM and the assigned Application Analyst in our Department. The Application Analyst will notify the Applicant of the status of the application.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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