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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803041
Report Date: 08/26/2022
Date Signed: 08/26/2022 11:31:15 AM


Document Has Been Signed on 08/26/2022 11:31 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:LA HOMA GUEST HOME, LLCFACILITY NUMBER:
286803041
ADMINISTRATOR:DASTGHEIB, ALIFACILITY TYPE:
740
ADDRESS:1161 LA HOMA DRIVETELEPHONE:
(707) 252-7426
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 5DATE:
08/26/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Acting Administrator, Ray GoTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 08/26/2022 to conduct a Case Management-Legal/Non-compliance inspection. Administrator was not available. LPA met with Ray Go, acting administrator. Upon entry LPA was screened for COVID symptoms.

LPA toured the facility with acting administrator. Facility was found to be clean and in good repair. All exits and walkways were clear and free from obstructions. Bathrooms had necessary grab bars and non-slip mats. Bedrooms had required furnishings. LPA observed one bed with half rails. Facility was able to provide physician's orders for rails. Medications were stored in a locked kitchen cabinet. Facility currently has 5 residents in care with 1 on hospice. Hospice exception was submitted to Community Care Licensing. Facility provided hospice binder which included an RCFE Care Plan Agreement. LPA reviewed resident records which were found to be current. LPA provided facility with regulation on resident records. LPA also provided guidance on annual training requirements for staff.

LPA is requesting updated copies of the following be submitted to Community Care Licensing by 09/02/2022:
LIC 308 Designation of Facility Responsibility
Liability Insurance
LIC 610E Emergency Disaster Plan
LIC 500
LIC 9020
Copies of staff training

Exit interview conducted with Ray Go and a copy of this report printed for the facility.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
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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