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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803041
Report Date: 08/27/2024
Date Signed: 08/27/2024 10:49:48 AM


Document Has Been Signed on 08/27/2024 10:49 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:
08/27/2024
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 Administrator Raymond Go, toured the facility and reviewed records. LPA toured building and grounds which was found to be clean and in good repair. Facility currently has 6 residents, none are receiving hospice services. There were three staff present during this inspection. The following items were focused on during this inspection:
Reporting Requirements: LPA reviewed unusual incident reports submitted by the facility and compared to resident records and interviews with staff. All situations that were required to be reported have been reported per regulation.
Incidental Medical and Dental Care: Based on records reviewed, all residents are able to communicate their needs.
Observation of the Resident: Based on records reviewed, all care plans are current and address the needs of the resident.
Personal Rights: LPA observed staff assisting residents with care needs with dignity.
Criminal Record Clearance: All staff present have passed a criminal record clearance and are associated to the facility.
Personnel and Resident Records: Resident records contained the required documents and were current. Personnel records were accurate and contained required documents.
Plans of correction: Facility has cleared all violations by the due date.

Exit interview conducted with Administrator 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: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
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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