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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216890070
Report Date: 04/18/2023
Date Signed: 04/18/2023 03:35:23 PM

Document Has Been Signed on 04/18/2023 03:35 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:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Staff Member, TIME COMPLETED:
03:40 PM
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At approximately 1:15PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Inspection Visit, and met with Staff Member, Romulo Damasco. Administrator, Ferdinand Alfonso, was available by telephone. The facility provides care to adults with developmental and physical disabilities and has an approved fire clearance for 6 Ambulatory clients. Upon arrival, LPA was informed that 5 of 5 clients were out of the community attending Day Program.

At approximately 1:20PM, LPA conducted a walk through of the facility and observed the following: LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Toxins were secure and not accessible to clients. There was a sufficient supply of hygiene products, paper products, and linens available for client use. Mattress pads were in place or available for client use.

The facility's last fire and evacuation drill was conducted January 2023. Facility's fire extinguishers were last inspected September 2022. Smoke detectors and carbon monoxide detectors were tested and operational. The amount of fresh and non-perishable foods was within regulation. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

LPA reviewed 5 of 5 Client records which were all found to be well organized, thorough and contained the required documentation. P&I monies were documented, secure and not commingled.

LPA unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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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