<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803706
Report Date: 06/20/2023
Date Signed: 06/20/2023 10:51:16 AM


Document Has Been Signed on 06/20/2023 10:51 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:LOMAS HOMEFACILITY NUMBER:
216803706
ADMINISTRATOR:CRUZ-LEON, LIBIAFACILITY TYPE:
740
ADDRESS:472 ALAMEDA DE LA LOMATELEPHONE:
(415) 234-6378
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY:4CENSUS: 4DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Libia Cruz-Leon (Administrator)TIME COMPLETED:
11:06 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Administrator Libia Cruz-Leon. Clients were attending to Day Program.

Upon arrival, LPA confirmed with Administrator that they are following current Covid19 and masks guidance. LPA initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and pathways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathrooms read at 105.3 and 106.4 which is within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable foods were available. Toxins are locked in a cabinet in the garage. Medications are centrally stored in locked cabinet in the dining room and medication records were reviewed. Fire extinguishers were last inspected August 2022. Smoke detectors and carbon monoxide detector are wired located throughout the facility were tested and operational. Most recent Fire/Disaster drill was conducted 6/5/23. Facility does have a current activity calendar and menu. Required postings were observed. First aid kit was fully stocked. Cash resources and documentation were reviewed. At 9:00am LPA conducted a file review of four client and six staff files. Clients records have updated care plans on file. CPR/1st aid certificates and training hours are current. Administrator Certificate for Libia Cruz-Leon 6036857740 expires 11/17/2023.

LPA obtained updates of the following documents: LIC500 (Personnel Report), LIC308 (Designation of facility responsibility), Surety bond, LIC400 (cash affidavit for clients) and lease agreement.

No deficiencies cited during today's inspection. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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 1