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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002983
Report Date: 08/16/2023
Date Signed: 08/16/2023 03:43:51 PM

Document Has Been Signed on 08/16/2023 03:43 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:SORONGON, ESPERANZAFACILITY TYPE:
734
ADDRESS:4841 LOCH LOMOND DRTELEPHONE:
(650) 580-3896
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 5CENSUS: 5DATE:
08/16/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Shiryl MishraTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a post-licensing inspection. LPA met with Shiryl Mishra, Assistant Administrator, and explained purpose of inspection. LPA wore the following Personal Protective Equipment, surgical mask.

LPA observed the presence of (2) direct support professionals, (1) licensed vocational nurse and (1) Assistant Administrator. LPA observed (5) clients present in care.

LPA and Assistant Administrator toured the interior of the facility including the common areas, (5) private clients bedrooms, kitchen, (1) shared shower room, and common areas. LPA observed the home to be clean, safe, and in good repair. In areas toured, no immediate health, safety, personal rights violation was observed.

During today's visit, LPA observed the facility to be testing out the back up generators. LPA observed the facility to have 2+ days of perishable and 7+ days nonperishable foods present in the facility. LPA was informed additional supplement will be delivered by Amazon later day of visit. Administrator Certificate posted to be current. LPA observed fire extinguisher serviced on July 19, 2023.

When asked if there are any concerns at the facility, Assistant Administrator stated there are no concerns with staffing, only parking concerns with the neighboring homes. Assistant Administrator stated the parking spaces in discussion are public spaces.

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

Exit interview was conducted. Copy of report provided to Assistant Administrator.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
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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