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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803917
Report Date: 03/27/2024
Date Signed: 03/27/2024 11:50:04 AM

Document Has Been Signed on 03/27/2024 11:50 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:SHALAMO HOMEFACILITY NUMBER:
216803917
ADMINISTRATOR:KIMBO, ANGELINEFACILITY TYPE:
737
ADDRESS:200 DARYL AVENUETELEPHONE:
(415) 493-6622
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 4CENSUS: 3DATE:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Jasmin GongoraTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:10AM to conduct an Annual Required inspection and was greeted by Administrator, Jasmin Gongora. LPA and Administrator discussed the purpose of the visit.

LPA and Administrator initiated a tour of the facility around 09:25 AM 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 116 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. Sharps were locked and facility keeps a check in log to ensure that sharps are returned and accounted for. 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. Personal Protective Equipment is stored in the garage. LPA and Administrator observed a broken glass bottle in the side yard. Administrator immediately disposed of it.

Facility has smoke and carbon monoxide detectors located throughout the facility as well as a sprinkler system. LPA did not test the alarms at the time of inspection as clients were in the facility and loud noises can be a trigger for behaviors. LPA and Administrator discussed testing them quarterly and keeping a log reflecting whether or not they were operational. Administrator informed LPA that maintenance comes out to replace the batteries yearly. LPA and Administrator discussed that during their next fire/disaster drill, they will test the smoke/carbon monoxide alarms and let LPA know the results of the test. Fire/disaster drills are conducted monthly with the last one taking place on 03/01/2024. Facility does not handle client cash resources at this time.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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: SHALAMO HOME
FACILITY NUMBER: 216803917
VISIT DATE: 03/27/2024
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Continued from LIC809

Three client files and five staff files were reviewed. Staff have required First Aid and CPR certificates. 1 of 5 staff did not have a medical assessment or tuberculosis results on file. Per conversation with Administrator, the staff did get the medical assessment done, and facility personnel were informed that the medical assessment would be mailed to the facility to keep on file. However, the facility never received it. Administrator agrees to send the medical assessment with TB results to LPA as soon as they receive it. Medications and medication records were reviewed. Administrator Certificate for Administrator, Jasmin Gongora (6055643735) is on the departments pending list.

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 04/27/2024:

LIC 500 Personnel Report
LIC 9020 Client Roster
LIC 308 Designation of facility responsibility
LIC 400 Affidavit regarding client cash resources
Surety Bond
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2