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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002983
Report Date: 11/21/2022
Date Signed: 11/21/2022 12:03:59 PM

Document Has Been Signed on 11/21/2022 12:03 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:
11/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shiryl Mishra and John PeleoTIME COMPLETED:
12:15 PM
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On 11/21/2022, Licensing Program Analysts (LPAs) Cassie Yang and Sabrina Calzada arrived at the facility unannounced to conduct a case management visit regarding the special incident report LPA Yang received from Long-Term Care Ombudsman (LTCO) Ron Carrera. LPAs met with Licensee and Assistant Facility Administrator. This was a joint visit with LTCO. Prior to the visit, LPAs 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. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask. Additionally, LPAs were screened at the facility by staff upon entry.

LPAs and Assistant Facility Administrator toured the interior of the facility to ensure the health and safety of clients in care. LPA observed (4) clients to be in their private rooms, and (1) client to be in the living room watching Kung Fu Panda. No immediate health, safety or personal rights violations were observed.

During today's visit, LPAs reviewed staff schedule for Week 11/14/22 - 11/20/2022, R1's file, and interviewed (2) direct staff professionals.

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

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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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