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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803041
Report Date: 05/19/2023
Date Signed: 05/19/2023 10:43:08 AM


Document Has Been Signed on 05/19/2023 10:43 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: 6DATE:
05/19/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Raymond GoTIME COMPLETED:
11:00 AM
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At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a Legal/Non-Compliance inspection. LPA met with lead staff Raymond Go, toured the facility and reviewed records. LPA toured building and grounds which was found to be clean and in good repair. Exits and walkways were clear from obstructions. Facility currently has 6 residents, one is on hospice. Facility has an approved hospice exception for resident. Medications are centrally stored and secured. Residents were observed participating in activities in the living room. Facility also had activity schedule posted. 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. LPA and lead staff reviewed Centrally Stored Medication/Destruction record and discussed the medication destruction policies of the facility. LPA provided information regarding FDA approved methods of destruction.

Exit interview conducted with lead staff, Raymond Go.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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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