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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002983
Report Date: 12/02/2022
Date Signed: 12/02/2022 02:47:09 PM

Document Has Been Signed on 12/02/2022 02:47 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:
12/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shiryl MishraTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a case management visit. LPA met with Facility Assistant Administrator, Shiryl Mishra, and explained the purpose of the visit. LPA arrived at the facility wearing a surgical mask and additionally, LPA was screened upon entrance by staff.

LPA and Facility Assistant Administrator toured the interior of the facility to ensure the health and safety of clients in care. LPA observed the facility to have the following staff present: (1) licensed vocational nurse, (1) registered nurse, (2) direct support professional, (1) Facility Assistant Administrator and (2) Co-Licensees to be present at the facility. In the areas toured, no immediate health, safety and personal rights violation were observed.

LPA observed two (2) clients to be working with staff, and three (3) clients to be resting alone in their private rooms. LPA and Facility Assistant Administrator discussed staff training. Facility Assistant Administrator informed LPA the facility just completed training with a registered dietian prior to the visit. Facility Assistant Administrator reported no concerns at this time.

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

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: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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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