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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804268
Report Date: 10/21/2024
Date Signed: 10/21/2024 05:08:07 PM

Document Has Been Signed on 10/21/2024 05:08 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:BENICIA GUEST HOMEFACILITY NUMBER:
486804268
ADMINISTRATOR/
DIRECTOR:		LAGO, ALEXFACILITY TYPE:
740
ADDRESS:234 MILITARY EASTTELEPHONE:
(925) 278-0086
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY: 3CENSUS: 0DATE:
10/21/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:12 PM
MET WITH:Alex LagoTIME VISIT/
INSPECTION COMPLETED:
04:58 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Pre-Licensing Inspection and met with Applicant/Administrator, Alex Lago. Home has an approved waiver for 2 Hospice residents.

This home is a one story residence with three resident bedrooms, 1 bathroom, living room, dining room, kitchen area and the garage. Resident rooms have the required furnishings in resident bedrooms. Bathroom showers have non-skid shower floors/mats and grab bars. Water temperature in bathrooms is within regulation of 105 & 120 degrees F. Home has sufficient items used for cooking and eating. Cleaning supplies and sharps are locked in kitchen closet. Personnel records, resident records and medications are stored in locked cabinet. Auditory alarms on doors were operational. Home received an approved fire clearance dated July 29, 2024, that allows for 3 non-ambulatory residents. Carbon monoxide and smoke alarms are operational. Fire extinguisher is charged and service 7/29/2024.

Required postings were observed. Administrator certificate for Alex Lago 7071006740 exp 7/18/2026. LPA went over a lower section of the property that has a separate unit, with its own entrance at the lower level and separate from home. Requirements for fingerprint clearance and association to the home.
Applicant to submit copy of Liability Insurance to Centralized Applications Bureau Analyst or LPA Canela.

Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation.

Component III was conducted today, with Applicant, Alex Lago and Michelle Lago.

Pre-Licensing is complete. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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