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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002983
Report Date: 11/02/2022
Date Signed: 11/02/2022 04:58:41 PM

Document Has Been Signed on 11/02/2022 04:58 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
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:
11/02/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Shiryl Mishra and Judy MusgroveTIME COMPLETED:
05:00 PM
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On 11/2/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit. This visit was joined by Regional Manager (RM) Alycia Berryman, and Alta Regional representative, Heather Hollingworth. Prior to initiating today's inspection, 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 and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA met with Assistant Facility Administrator, Shiryl Mishra, and was informed that Lovella Lucero had came to the facility approximately at 12:55 PM and took facility properties.

The items taken from the facility by Lovella Lucero:
- Facility nurse iphone
-Assistant Administrator's work iphone
-Assistant Administrator's work laptop
-Assistant Accountant/Bookkeeper's work laptop

LPA toured the facility to ensure the health and safety of clients in care as 2 (C1 and C2) out of 5 clients were present during the altercation. LPA spoke with C1 who stated "I want Lovella out of my house." C1 further asked LPA "what are you going to do about it?". LPA ended the conversation as LPA observed C1 to be in distressed regarding the incident. LPA observed C2 to not be verbal. LPA observed (3) other clients in their private bedroom.

Please continue LIC 809-D...
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: LOMOND HOME
FACILITY NUMBER: 345002983
VISIT DATE: 11/02/2022
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Continued from LIC 809...

LPA observed S1 and S2 writing their statements regarding the incident. LPA was informed the facility has contacted local law enforcement. Facility informed LPA that police report number will be provided to LPA once it is completed.

During today's visit, LPA took (1) photo of the Best Buy receipt, and took statements of S1 and S2. Staff will also provide LPA copies of the written statements once completed..

As a result of today's visit, no deficiencies were cited.

Exit interview conducted and a copy of the report was provided at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC809 (FAS) - (06/04)
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