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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803706
Report Date: 07/25/2024
Date Signed: 07/25/2024 02:37:37 PM


Document Has Been Signed on 07/25/2024 02:37 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: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:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrators, Shella Pastor and Libia Cruz-LeonTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 11:15AM to conduct an Annual Required inspection. Administrators, Shella Pastor and Libia Cruz-Leon arrived shortly after.

LPA and Administrator initiated a tour of the facility around 12:00PM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 111 and 112 degrees F which is within the range of 105 to 120 degrees F allowed per regulation.

Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is stored in the garage.


Fire extinguishers were last serviced May 23, 2024. Facility has combination smoke and carbon monoxide detectors located throughout the facility that were tested and operational during inspection. Facility is equipped with fire doors on all doors. Most recent fire/disaster drill was conducted 04/17/2024. Client cash resources were reviewed.

Five staff files and four resident files were reviewed. Staff have required First Aid and CPR certificates. Medications and medication records were reviewed. Administrator Certificate for Administrator, Libia Cruz-Leon (7010783740) is up to date and expires 11/17/2025.

Continued on LIC809C
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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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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: LOMAS HOME
FACILITY NUMBER: 216803706
VISIT DATE: 07/25/2024
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Continued from LIC809

No deficiencies cited during inspection.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on forms confirms receipt of documents.

LPA is requesting the following documents to be submitted to Community Care Licensing by 08/25/2024:


LIC 500 Personnel Report

LIC 9020 Resident Roster
LIC 308 Designation of facility responsibility
Surety Bond
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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