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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804234
Report Date: 05/09/2024
Date Signed: 05/16/2024 08:58:35 AM

Document Has Been Signed on 05/16/2024 08:58 AM - 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:ANICA HOMECAREFACILITY NUMBER:
486804234
ADMINISTRATOR/
DIRECTOR:		VILLEGAS, ARTFACILITY TYPE:
740
ADDRESS:1001 BRETON DRIVETELEPHONE:
(707) 344-0839
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 6DATE:
05/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Art Villegas, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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At approximately 12:15PM, Licensing Program Analyst (LPA) Julie Florio arrived at this facility announced for the purpose of completing a pre-licensing evaluation.. LPA met with Applicant Art Villegas and toured the facility. The facility is a 5-bedroom, 2-bathroom, single story house. Two bedrooms are shared rooms, one of which has a private bathroom. The facility has been approved for 6 non-ambulatory residents and 3 of which can be on Hospice. Fire extinguishers were charged and inspected April 2024. Smoke detectors were tested and in working order. There was a locked area for medications and several for toxins and cleaning supplies. Applicant informed LPA that he does not currently have a centrally stored medication log. LPA advised Applicant to obtain one from the CCL website. Beds were made but each was missing a mattress pad. LPA advised Applicant that each bed shall have a mattress pad per regulation. Resident rooms contained the required furniture in 5 of 5 rooms, however the trash cans were without tight fitting lids as required per regulation. LPA advised Applicant that all trash cans shall have a tight fitting lid. Hot water temperature was tested and found to be within regulation between 105 degrees F and 120 degrees F at faucets accessible to residents.

This facility has an emergency disaster plan, infection control plan, dementia care plan. LPA observed an insufficient supply of emergency food and water to sustain 6 residents for 7 days as required per regulation. LPA advised Applicant to provide proof of the purchase of more of these items. LPA observed a weekly menu posted in a common area but was informed that the facility does not have an activity schedule at this time. LPA observed a supply of games and a karaoke machine present, and advised Applicant to provide an activity schedule to LPA.

Component III orientation was conducted at facility. Applicant conveyed a good knowledge of Title 22 regulations. Applicant stated he will obtain liability insurance upon receipt of the License.

Continued on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ANICA HOMECARE
FACILITY NUMBER: 486804234
VISIT DATE: 05/09/2024
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Continued from LIC809

Applicant to submit proof of correction (POC) for each technical violation form LIC9102 provided before LPA will submit the application packet for a final review and approval from the Licensing Program Manager.

Exit interview conducted. Copy of report and copies of each LIC9102 discussed and provided to Applicant. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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