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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002983
Report Date: 11/26/2024
Date Signed: 11/26/2024 04:10:48 PM

Document Has Been Signed on 11/26/2024 04:10 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: 4DATE:
11/26/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:04 PM
MET WITH:Shiryl MishraTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 11/26/2024, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to complete the require annual inspection utilizing the care tool. LPA met with Assistant Administrator and explained the purpose of the visit.

During todays visit, LPA and Assistant Administrator conducted a tour on the interior of the facility to ensure the healthy and safety of clients in care. In areas toured, no immediate health, safety and/or personal rights violation was observed.

LPA observed the presence of two direct support professionals, and one licensed vocational nurse to be working at the facility. LPA observed four clients in their private rooms. LPA observed fire extinguishers to be in good condition, recently serviced on May 20, 2024.

Administrator Certificate #6070896735 observed to be active with expiration date of 6/7/2024 to 6/6/2026. LPA informed Assistant Administrator if Licensee wish to appoint another Administrator on file, to submit LIC 308 along with a copy of the Administrator Certificate and resume.

File review conducted for clients records, and observed the required documents to be on file and completed. Inspection tool was completed and found facility to be in substantial compliance.

As a result of today's inspection, no deficiencies observed.

Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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