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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804261
Report Date: 02/21/2025
Date Signed: 02/21/2025 03:45:05 PM

Document Has Been Signed on 02/21/2025 03:45 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:CARE HOME AT PEACOCK, THEFACILITY NUMBER:
486804261
ADMINISTRATOR/
DIRECTOR:		CALIMPON, LUCILLE ANNEFACILITY TYPE:
740
ADDRESS:475 PEACOCK WAYTELEPHONE:
(707) 430-1608
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 5DATE:
02/21/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:03 PM
MET WITH:Lucille Anne Calimpon, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted a pre-licensing inspection, at approximately 1:08 PM on 02/21/2025, and met with Administrator Lucille Anne Calimpon and Licensee Applicant Robert Coleman by phone. Lucille has a residential care for the elderly administrator certificate, 6074536740 expires 01/20/2027.

Facility has a fire clearance approval by the County Fire Department for a total of six (6) non-ambulatory, of which one (1)) may be bedridden. Bedridden room #1 only. Applicant has applied for approval of a dementia plan of operation. Applicant has also applied for an approval of a hospice waiver for six (6). Licensee will ensure sufficient 24/7 staffing at all times.

All exits were unobstructed in the home. All exit doors had auditory alarms and the alarms were working properly during the inspection. Fire extinguisher is serviced and tagged as required- 03/29/2024.. There are seven (7) smoke alarms and two (2) carbon monoxide detectors which were functioning at the time of inspection..

Facility has a sufficient supply of food, perishable and non-perishable There is a closet used for storage of resident medications, and is kept locked at all times, with a key-code entry pad.

LPA observed sufficient supply of cleaners, paper products, hygiene products, and personal protective equipment (PPE).
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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: CARE HOME AT PEACOCK, THE
FACILITY NUMBER: 486804261
VISIT DATE: 02/21/2025
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 There is a large backyard but there were no amenities at the time of inspection. There is an enclosed courtyard with table, chairs and umbrella available for resident and visitor use.

There was sufficient lighting throughout the facility in resident rooms, common areas, bathrooms, and hallways. The grounds were free of any apparent hazards, and exits were clear during the inspection. No bodies of water. No firearms. All bathrooms had grab bars for resident use, and mats/non-skid flooring for resident use. There is a sign in and sign out log at the front door. All postings required were posted, and visible upon entry into the facility.

LPA reviewed three (3) resident files and three (3) staff files which were found to be complete.

LPA found a broken window which is in the process of being repaired.

LPA conducted a component III orientation with Administrator Lucille Anne Calimpon, on 02/21/2025.

LPA will be informed of repair by Licensee and final inspection will be completed at that time.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC809 (FAS) - (06/04)
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