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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002983
Report Date: 11/21/2024
Date Signed: 11/21/2024 03:42:13 PM

Document Has Been Signed on 11/21/2024 03:42 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LOMOND HOMEFACILITY NUMBER:
345002983
ADMINISTRATOR/
DIRECTOR:		SORONGON, ESPERANZAFACILITY TYPE:
734
ADDRESS:4841 LOCH LOMOND DRTELEPHONE:
(650) 580-3896
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 5CENSUS: 5DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:02 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection. LPA met with staff and explained the purpose of the visit.

During today's visit, LPA conducted a tour included but not limited to five clients room, kitchen, bathroom, laundry room. In middle of inspection, LPA experienced technical difficulties. LPA informed facility LPA will return again at a later date to complete inspection.

Exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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