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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803943
Report Date: 02/19/2025
Date Signed: 02/19/2025 01:04:15 PM

Document Has Been Signed on 02/19/2025 01:04 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:ALAMEDA HOMEFACILITY NUMBER:
216803943
ADMINISTRATOR/
DIRECTOR:		LIU, FANGFACILITY TYPE:
735
ADDRESS:405 ALAMEDA DE LA LOMATELEPHONE:
(415) 516-3162
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 4CENSUS: 3DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Wen Liu, House Manager
Fang Liu, Administrator		TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analysts (LPAs) Star Stevenson and Anthony Loera arrived unannounced at approximately 10:05 AM to conduct an Annual Required inspection. All 3 clients were at day program during inspection. House manager Wen Liu arrived at approximately 10:20 AM. Administrator, Fang Liu arrived shortly after.

LPAs initiated a tour of the facility at approximately 10:55 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 and observed to be within the range of 105 to 120 degrees F per regulation. Extra hygiene products, personal protective equipment (PPE) 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 is stored in hall closet and emergency water is stored in the office. New fire sketch was observed to contain 12ftx16ft shed in backyard installed last year.

Fire extinguishers were last serviced of May 2024 and administrator reports fire department with plans to re-inspect. Facility has combination smoke/ carbon monoxide detectors located throughout the facility that were tested and operational during inspection. Most recent fire/disaster drill was conducted 12/25/2024. Medications and medication records were reviewed. Client cash resources were reviewed and were observed to not be co-mingled.

Five (5) staff files and three (3) resident files were reviewed and found to have all required documentation.
LPAs observed sample healthy menu, as wells as, activities provided clients including games, gardening, walks, music, restaurants, art etc. Clients also participate in outside day programming.


Continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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: ALAMEDA HOME
FACILITY NUMBER: 216803943
VISIT DATE: 02/19/2025
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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 to be submitted to Community Care Licensing by 03/19/2025:
LIC 500- Personnel Report
LIC 308 Designation of facility responsibility
Surety Bond
Emergency Disaster Plan (Review and update if needed)
Infection Control Plan (Review and update if needed)
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
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