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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804234
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:42:21 PM

Document Has Been Signed on 08/23/2024 03:42 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:ANICA HOMECAREFACILITY NUMBER:
486804234
ADMINISTRATOR/
DIRECTOR:
VILLEGAS, ARTFACILITY TYPE:
740
ADDRESS:1001 BRETON DRIVETELEPHONE:
(707) 344-0839
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 1DATE:
08/23/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Art Villegas, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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On 8/23/2024, at approximately 2:30 PM, Licensing Program Analyst (LPA) Julie Florio arrived at the facility to conduct a post-licensing inspection with Art Villegas, Licensee/Administrator. The facility currently has 1 resident in care and 4 staff members who are background cleared and associated.

The facility is a one-story home, has 4 bedrooms, 2 baths, a common area, a shaded, furnished deck in the backyard, and additional yard space for activities. LPA inspected a locked structure in the backyard and observed mostly personal items, decorations, and tools within. Facility has an auditory signal system which was operational during today's inspection. LPA observed the required postings in the main entryway at the front door of the facility. The grounds were free of any apparent hazards, passageways were free from obstruction, and fire exits were clearly marked. LPA observed locked cabinets for resident and staff records, medications, chemicals, and sharps. LPA observed a first aid kit, emergency supplies, and PPE. Kitchen was spacious and clean with a supply of dishes and utensils. LPA observed at least a two (2) supply of perishable and a seven (7) day supply of nonperishable foods appropriately labeled and dated. The laundry area with laundry supplies is locked and secured with a keypad for employees to access. Facility has an internet access device in the main common area for resident use.

The resident in care remarked that their needs are met and they like the facility. Licensee/Administrator states the facility is working with a few referral agencies for additional resident placement.

No deficiencies found at the time of inspection. No citations issued.

Exit interview conducted with Licensee/Administrator, whose signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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