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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801077
Report Date: 04/16/2024
Date Signed: 04/16/2024 11:18:15 AM

Document Has Been Signed on 04/16/2024 11:18 AM - 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. - PEACH STONE HOMEFACILITY NUMBER:
216801077
ADMINISTRATOR/
DIRECTOR:		AGNES DIZONFACILITY TYPE:
735
ADDRESS:440 PEACH STONE TERRACETELEPHONE:
(415) 479-6580
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 4DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Designated Representative, Allen YangTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Bo Yang. Designated Representative, Allen Yang, arrived to the facility at approximately 9:45AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance for 3 ambulatory and 3 non-ambulatory clients with a total capacity of 6 Clients. Upon arrival, LPA was informed that there were 4 clients in care, with all clients out of the community attending Day Program.

At approximately 9:35AM, LPA 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 9:45AM, LPA conducted a walk-though of the facility and 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 two story building with 3 Client bedrooms, 2 staff rooms, 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. 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 10:30AM, LPA reviewed staff and client files, client medication, and P&I monies. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. P&I monies were documented, secure and not commingled. Medication was observed to be centrally stored and secure. Administrator's Certificate for Agnes Dizon (6026680735) was current with an expiration date of 06/25/2025.

Fire extinguishers were last inspected October 2023. Smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency drill was conducted April 2024.



Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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. - PEACH STONE HOME
FACILITY NUMBER: 216801077
VISIT DATE: 04/16/2024
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Continued from LIC809

LPA requested the following documents to update facility file:
  • Affidavit regarding Client/Resident Cash Resources (LIC400)
  • Designation of Facility Responsibility (LIC308)
  • Emergency Disaster Plan (LIC610D)
  • Updated Personnel Report (LIC500)
  • Surety Bond (LIC402)
  • Register of Clients/Residents (LIC9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate


Documents to be submitted to Community Care Licensing (CCL) by due date of 05/16/2024.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Designated Representative. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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