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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803041
Report Date: 11/17/2022
Date Signed: 11/17/2022 02:48:54 PM


Document Has Been Signed on 11/17/2022 02:48 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: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:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Lead Staff, Ray GoTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 11/17/2022 to conduct a Required - 1 Year inspection. This inspection also serves as a Legal/Non-Compliance inspection. LPA met with lead staff, Ray Go.

LPA toured building and grounds which were clean and in good repair. Exits and walkways were clear from obstructions. Facility currently has 5 residents, one is on hospice. Facility has approved hospice exception for resident. Medications are centrally stored and inaccessible. Toxins are locked and inaccessible. LPA observed sufficient perishable and non-perishable food as well as a menu posted. Fire extinguishers were charged and current. Carbon monoxide and smoke detectors were present and operational. Bathrooms had necessary grab bars and non-slip mats. Residents are being screened daily. Facility staff were observed wearing masks. All staff and residents are fully vaccinated and boosted. Visitation is allowed indoors. LPA reviewed personnel records. 5 Staff had current CPR/First aid training, valid until November, 2024. LPA provided lead staff with regulations on annual training. LPA and lead staff had conversation regarding temperature in facility, LPA provided regulation.

LPA was unable to print report. Report emailed to administrator.

Exit interview conducted with lead staff, Raymond Go.

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: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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