216890070-10-13-2021-21-AS-FSAI-C7RNH4-20211013102805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216890070
Report Date: 10/13/2021
Date Signed: 10/13/2021 10:28:55 AM

Document Has Been Signed on 10/13/2021 10:28 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	HACIENDA HOME		FACILITY NUMBER:	216890070
ADMINISTRATOR:	ALFONSO, FERDINAND		FACILITY TYPE:	735
ADDRESS:	833 DESCANSO WAY		TELEPHONE:	(415) 491-0226
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY: 6		CENSUS: 5	DATE:	10/13/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Caregiver, Romul Damasco		TIME COMPLETED:	10:45 AM

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Licensing Program Analyst (LPA) Farhaan Sarangi conducted an unannounced Annual Required inspection. The purpose of this inspection is for a Post Licensing. LPA was greeted at the door by Caregiver, Romul Damasco, and granted access into the facility.

LPA toured facility with Care Giver Romulo Damasco. Facility is a one floor building. The facility was inspected and found to be cleaned and at in good repair. Fire Extinguishers are dated for April 2021. Smoke detectors and carbon monoxide detector were found to be working at this time. Hot water temperature could not be checked due to not having a gauge available. The facility has a phone line designated for resident’s use. Hot water temperature measured between 116 degrees F and 108 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in all bathrooms while touring. There was an ample supply of personal hygiene products, bedding and linens, utensils, dishes, and cook ware as per facility. There were emergency supplies available at the time of the visit. Medications, Personnel records and client’s records are stored at the facility in locked cabinets. There was an ample supply of perishable and non-perishable foods. Clients bedrooms have all required lighting & appropriate furnishings as per Title 22 Regulations. Activities are available for residents as per licensee and administrator. There is outdoor space for activities.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Mitigation Plan was discussed with licensee via telephone and Caregiver, Romul Damasco. Facility has sufficient Personal Protective Equipment (PPE). Licensee indicated that more PPE is on order. Facility is in the process of being N95 Fit tested. No deficiencies were observed or cited during today's Annual Required inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Ferdinand Alfonso.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

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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