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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801077
Report Date: 03/28/2023
Date Signed: 03/28/2023 03:19:07 PM

Document Has Been Signed on 03/28/2023 03:19 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:CAREMAX, INC. - PEACH STONE HOMEFACILITY NUMBER:
216801077
ADMINISTRATOR:AGNES DIZONFACILITY TYPE:
735
ADDRESS:440 PEACH STONE TERRACETELEPHONE:
(415) 479-6580
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 4DATE:
03/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Administrator, Agnes DizonTIME COMPLETED:
03:25 PM
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At approximately 12:55PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required - 1 Year Inspection visit and met with Staff Member, Maria Chiu. Licensee, Willie Yang, arrived later during visit at 1:10PM and Administrator, Agnes Dizon, during visit at approximately 1:15PM. The facility provides care to adults with developmental and physical disabilities and has an approved fire clearance for 3 ambulatory clients and 3 non-ambulatory clients, for a total of 6 clients. Upon arrival, LPA was informed that 4 of 4 clients were out of the community attending Day Program.

At approximately 1:20PM, LPA conducted a walk through of the facility and observed the following: LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom showers. Toxins were secure and not accessible to clients. Medication was centrally stored and secure. There was a sufficient supply of hygiene products, paper products, and linens available for client use. Mattress pads were in place or available for client use.

The facility's last fire and evacuation drill was conducted March 2023. Facility's fire extinguishers were last inspected November 2022. Smoke detectors and carbon monoxide detectors were tested and operational. The amount of fresh and non-perishable foods was within regulation. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

LPA reviewed 4 of 4 Client records which were all found to be well organized, thorough and contained the required documentation. P&I monies were documented, secure and not commingled. First Aid and CPR certification were current for 5 of 5 staff files reviewed. Administrator's Certificate (6026680735) was current with an expiration date of 06/24/2023.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CAREMAX, INC. - PEACH STONE HOME
FACILITY NUMBER: 216801077
VISIT DATE: 03/28/2023
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Continued from LIC809

LPA requested the following documents to update facility file:
  • Administrative Organization (LIC 309)
  • Affidavit regarding Client/Resident Cash Resources (LIC 400)
  • Control of Property
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Facility Sketch
  • Updated Personnel Report (LIC 500)
  • Surety Bond (LIC 402)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by due date of 4/28/2023.

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: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC809 (FAS) - (06/04)
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