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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803041
Report Date: 05/10/2022
Date Signed: 05/10/2022 12:33:45 PM


Document Has Been Signed on 05/10/2022 12:33 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:
05/10/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ray GoTIME COMPLETED:
12:45 PM
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Case Management Legal/Non-Compliance visit. LPA met by Staff Member Ray Go. LPA observed signs at the entry way to inform visitors of the visiting policy of the facility. LPA had temperature checked and health questions asked upon entry. Facility has 5 residents, 1 of which receives Hospice services. Facility has submitted all required paperwork for this Hospice resident. LPA toured the facility and found it to be clean and in good repair. Resident rooms were clean and had a pleasant odor. Medications were secure and not accessible. Resident records were inspected and found to be up to date. Hospice care plan on file. Staff training is in process, but on track to have all required annual training.

No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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