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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701116
Report Date: 02/23/2022
Date Signed: 02/23/2022 04:50:24 PM


Document Has Been Signed on 02/23/2022 04:50 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:LAKEWOOD VILLAFACILITY NUMBER:
342701116
ADMINISTRATOR:QUIAMBAO, GLADYSFACILITY TYPE:
740
ADDRESS:8708 GERBER ROADTELEPHONE:
(925) 954-5329
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:18CENSUS: 15DATE:
02/23/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:applicant Gary QuiambaoTIME COMPLETED:
04:50 PM
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Announced Pre-licensing visit made out to this facility on 02/23/2022. LPA Anthony Tuck was met by the Applicant, Gary Quiambao, who was briefly interviewed by LPA Anthony Tuck. LPA was also met by current Licensee Hope Villaluna and Administrator Gladys Quiambao.
It was learned that this facility will be licensed to serve up to (18) residents of which 9 may be non ambulatory, and 6 may be bed ridden at any given time. This Applicant was also seeking a program for dementia care and a hospice waiver to accept and retain up to (3) hospice residents at any given time.
There were 15 residents in care during today's Pre-licensing visit due to a change in ownership.
Tour of the facility was conducted. Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time.
Kitchen area was toured. Cabinets and drawers were opened and reviewed by LPA Tuck along with the Applicant. Knives and other sharp utensils were observed to be locked in a cabinet to make them inaccessible to the residents at all times.
Food supply for 2-day perishable and 7-day nonperishable quantities were reviewed to make sure that this facility was in compliance at this time.
Medication cabinet, located in the hallway area, was toured. First aid kit was observed to be present and contained all required components at this time.
A tour of the (4) private resident bedrooms and 7 shared rooms were toured. It was observed that 3 resident bedrooms were equipped with direct exits at this time.
Furnishings and furniture intended for use by the residents were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident bathrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Grab bars and nonskid mats were observed to be present and in compliance at this time.
Laundry area was toured. All cleaning agents and detergents were observed to be locked and made inaccessible at this time.

continued on LIC 809C....

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: LAKEWOOD VILLA
FACILITY NUMBER: 342701116
VISIT DATE: 02/23/2022
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Linen closet, located in the hallway, was observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time.
A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. Gate latches were reviewed and observed to be functional and allowed access for emergency response. All proper posters were posted on walls. All smoke detectors were operational, and the carbon monoxide detector was operational.

There were 0 deficiencies observed during today's Pre-licensing visit.

Component III interview was conducted with the Applicant and completed during today's Pre-licensing visit.

Exit Interview conducted with applicant Gary Quiambao. A copy of this report was provided to the applicant upon exit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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