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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216890070
Report Date: 02/11/2022
Date Signed: 02/11/2022 03:18:32 PM

Document Has Been Signed on 02/11/2022 03:18 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HACIENDA HOMEFACILITY NUMBER:
216890070
ADMINISTRATOR:ALFONSO, FERDINANDFACILITY TYPE:
735
ADDRESS:833 DESCANSO WAYTELEPHONE:
(415) 491-0226
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 5DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Caregiver, Romul DamascoTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Farhaan Sarangi conducted an unannounced Required 1 year inspection at Hacienda Home. LPA was greeted at the door by Caregiver, Romul Damasco, and granted access into the facility.

LPA toured facility with Caregiver, Romul Damasco on February 11, 2022. 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 operational and working at the time of the inspection. 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 and dishes were observed. First Aid kit was found to be appropriate during the inspection. 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. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are to be stored in a locked and inaccessible to clients in care. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has sufficient Personal Protective Equipment (PPE). Facility has is in the process of obtaining N95 Fit testing by the end of February 2022. No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
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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