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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216890070
Report Date: 04/25/2023
Date Signed: 04/25/2023 12:43:06 PM

Document Has Been Signed on 04/25/2023 12:43 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:
04/25/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Ferdinand Alfonso TIME COMPLETED:
12:50 PM
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At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct an Annual Continuation Visit. Administrator, Ferdinand Alfonso, arrived at approximately 10:15AM and greeted LPA. Upon arrival, LPA was informed that 3 of 5 clients were out of the community.

During visit, LPA reviewed staff files, medication records, and conducted staff and client interviews. Medication was observed to be centrally stored and secure. First Aid and CPR certification were current for 2 of 2 staff files reviewed. Administrator's Certificate (6001350735) was current with an expiration date of 06/02/2023.

LPA requested the following documents to update facility file:
  • Affidavit regarding Client/Resident Cash Resources (LIC 400)
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Surety Bond (LIC 402)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by due date of Thursday, 5/25/2023.

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: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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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