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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701241
Report Date: 07/15/2024
Date Signed: 07/15/2024 12:36:42 PM

Document Has Been Signed on 07/15/2024 12:36 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BUEN VIAJE RESIDENCEFACILITY NUMBER:
342701241
ADMINISTRATOR/
DIRECTOR:		BUENVIAJE, SHERINIEFACILITY TYPE:
735
ADDRESS:3419 KLEVNER WAYTELEPHONE:
(818) 631-4890
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 4CENSUS: 3DATE:
07/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Sherinie BuenviajeTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 07/15/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct an annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to speak with the Designated Facility Administrator (DFA). LPA met with Sherinie Buenviaje and a brief interview followed. LPA noted DFA’s certificate # 7022268735 and it expires on 10/02/2025.

LPA inspected 4 resident rooms. All had the required furniture furnishings and lighting to be in compliance at the present time. LPA also viewed staff quarters as depicted on facility sketch.

The LPA inspected the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. All foods in the refrigerator and freezer were packaged and dated appropriately. The fire extinguisher was last serviced on 03/13/24 by River City Fire Extinguisher Company and was in compliance at the time of inspection.

LPA inspected a total of 2 bathrooms. Each contained soap, paper towels, and trash cans with lids as required. Hot water was measured to ensure the temperature was between 105 and 120 degrees Fahrenheit in order to be in compliance.

The LPA observed medications were stored in a locked cabinet in the kitchen and inaccessible to residents in care. Medications were primarily the pill packs. LPA reviewed storage, dosing, and destruction procedures. A review of the First Aid kit by the LPA found it to be complete and in compliance.

The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. There were also sitting areas in shaded locations in the rear of the house for residents to enjoy.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BUEN VIAJE RESIDENCE
FACILITY NUMBER: 342701241
VISIT DATE: 07/15/2024
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LPA observed an activity calendar, menu calendar, facility license, IF YOU SEE SOMETHING, SAY SOMETHING sign, along with resident and employee rights posters.

LPA conducted a sample file review. LPA reviewed 3 staff files and all were in compliance at the present time. LPA also compared staff roster to Guardian roster to ensure background checks had been completed.

LPA reviewed 3 resident files 1 out of 3 was missing the most recent LIC 602. Administrator explained difficulties she had been having obtaining an appointment to obtain a new LIC 602 since the annual was not due until August. LPA provided technical assistance.

LPA compared facility sketch with actual facility layout and found that walls had been added to a section of the garage to add an office for the Designated Facility Administrator. The capacity of the facility had not changed but the footprint had, so the LPA provided technical assistance with regard to supplying Community Care Licensing with an updated facility sketch, obtaining a building permit, and notifying the appropriate agencies.

According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC809 (FAS) - (06/04)
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