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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002983
Report Date: 11/01/2022
Date Signed: 11/01/2022 11:32:54 AM

Document Has Been Signed on 11/01/2022 11:32 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:LOMOND HOMEFACILITY NUMBER:
345002983
ADMINISTRATOR:SORONGON, ESPERANZAFACILITY TYPE:
734
ADDRESS:4841 LOCH LOMOND DRTELEPHONE:
(650) 580-3896
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 5CENSUS: 5DATE:
11/01/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Shiryl Mishra and Esperanza SorongoTIME COMPLETED:
11:45 AM
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On November 1, 2022 at 10:30 AM, Licensing Program Analyst (LPA) Cassie Yang arrived to conduct the pre-licensing inspection. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask and disposable gown.

Due to time constraints, Licensee was only able to joined the inspection via Microsoft Teams. LPA, Assistant Facility Administrator and Licensee Esperanza Sorongo completed the pre-licensing inspection and the facility was found to be in compliance at this time. LPA, Assistant Administrator, and Licensee conducted a walk through of the facility and ensured all physical plant requirements.

LPA advised facility to lock all toxins in laundry room. LPA informed facility that emergency fire exit pathway cannot be blocked. LPA informed facility that documentation of client turning log will need to be enforced as LPA observed (1) client log not signed.

LPA will notify CAB that the facility is ready for licensure.

Exit interview conducted. A copy of this report was emailed to Licensee.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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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