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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800414
Report Date: 02/28/2025
Date Signed: 02/28/2025 02:09:39 PM

Document Has Been Signed on 02/28/2025 02:09 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:CAREMAX, INC. - DELGANADO HOUSEFACILITY NUMBER:
216800414
ADMINISTRATOR/
DIRECTOR:		DIZON, AGNESFACILITY TYPE:
735
ADDRESS:786 DELGANADO ROADTELEPHONE:
(415) 507-0955
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 4DATE:
02/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Agnes Dizon, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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At approximately 12:15PM, Licensing Program Analysts (LPAs) Felias and Magdaleno arrived unannounced to conduct a Required 1 Year visit. Administrator, Agnes Dizon, arrived to the facility at approximately 1:00PM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPAs were informed that there were 4 clients in care with all four clients out of the facility attending Day Program.

At approximately 1:05PM, LPAs conducted a walk-though of the facility with Administrator. LPAs observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 5 Client bedrooms, 2 bathrooms, and common areas. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Trash cans with lids were available to clients. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. At approximately 1:20PM, LPAs reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation

At approximately 1:30PM, LPAs reviewed staff files, client files and client medication. Client P&I monies are managed by Newleaf and bank statements were reviewed. All files were found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure. Administrator's Certificate for Agnes Dizon (6026680735) was current with an expiration date of 06/24/2025.

Fire extinguishers were last inspected October 2024. Smoke detectors and carbon monoxide detectors were tested and operational. The last facility fire/disaster drill was conducted in February 2025.



Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: CAREMAX, INC. - DELGANADO HOUSE
FACILITY NUMBER: 216800414
VISIT DATE: 02/28/2025
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Continued from LIC809

LPAs requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate


Documents to be submitted to Community Care Licensing (CCL) within 30 days of visit.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC809 (FAS) - (06/04)
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