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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002983
Report Date: 11/10/2022
Date Signed: 11/10/2022 11:28:12 AM

Document Has Been Signed on 11/10/2022 11:28 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:
11/10/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Shiryl Mishra- Assistant Facility Administrator TIME COMPLETED:
12:00 PM
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On 11/10/2022 at 11:00 AM, Licensing Program Analyst (LPA) Sarena Keosavang arrived unannounced at the facility to conduct a Case Management- Health Checks inspection. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. LPA met with Assistant Facility Administrator, Shiryl Mishra, and explained the purpose of the visit.

At 11:10 AM, LPA toured the facility together with Assistant Facility Administrator to ensure health and safety of residents in care. LPA toured five (5) resident rooms, bathroom, kitchen, laundry room, and common areas. LPA observed staffing is adequate. LPA received requested documents such as copies of staffing schedule and LIC500.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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