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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236801013
Report Date: 09/22/2023
Date Signed: 09/22/2023 12:22:57 PM


Document Has Been Signed on 09/22/2023 12:22 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:ROMES CARE FACILITY IFACILITY NUMBER:
236801013
ADMINISTRATOR:ALCASID, CHRISTINAFACILITY TYPE:
740
ADDRESS:1127 SOUTH DORATELEPHONE:
(707) 468-5986
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:6CENSUS: 0DATE:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Eliseo AlcasidTIME COMPLETED:
12:30 PM
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At approximately 11:15AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Licensee Eliseo Alcasid. At approximately 11:30AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored and not accessible. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways.
There are currently no residents residing at the care home.
LPA reviewed staff records and found evidence of completed training as required and evidence of current first aid and CPR.
LPA reviewed the facility emergency disaster plan. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. LPA received evidence of Liability insurance during visit.
Updated copy of the following document was requested for facility file and is to be submitted to CCL within 30 days of this visit:
Evidence of control of property

No citations issued during this visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
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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