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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803707
Report Date: 03/05/2025
Date Signed: 03/05/2025 03:02:21 PM

Document Has Been Signed on 03/05/2025 03:02 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:LUNA'S HOMEFACILITY NUMBER:
216803707
ADMINISTRATOR/
DIRECTOR:		CRUZ-LEON, LIBIAFACILITY TYPE:
740
ADDRESS:1027 LAS PAVADAS AVENUETELEPHONE:
(650) 387-9488
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 4TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Libia Cruz-Leon, Administrator
Shella Pastor, Lead Staff		TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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03/05/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 4 residents in care. Facility approved/cleared for 4 non-ambulatory and hospice waiver for 1. Upon arrival no staff or residents were present. LPA made a phone call and Lead staff, Shella Pastor arrived shortly after. Administrator Libia Cruz-Leon arrived at approximately 12:00 PM to assist with inspection.

At approximately 11:45 AM, LPA and lead staff toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

All rooms were furnished per regulation. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 109.4 and 110.5 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 05/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to residents were located in the garage and under the kitchen sink and found to be secured. Personal Protective Equipment is stored in the garage. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Cash resources were documented.

LPA conducted a review of 4 resident records. All records had the required documentation. LPA conducted review of 4 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file. Facility conducts quarterly fire and disaster drills with the last one being conducted 01/13/2025.

continued on LIC809C
Kimberley MotaTELEPHONE: (707) 588-5071
Anthony LoeraTELEPHONE: (707) 588-5026
DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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: LUNA'S HOME
FACILITY NUMBER: 216803707
VISIT DATE: 03/05/2025
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No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/06/2025:

LIC500- Personnel Report
LIC400- Affidavit Regarding Client/Resident Cash Resources
Updated Liability Insurance

Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
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