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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002983
Report Date: 11/30/2023
Date Signed: 11/30/2023 10:57:28 AM

Document Has Been Signed on 11/30/2023 10:57 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
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: 4DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Assistant Administrator- Shiryl MishraTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to the facility to conduct a Required 1-year annual inspection. LPA met with Assistant Administrator, Shiryl Mishra, and explained purpose of inspection. LPA wore the following Personal Protective Equipment, surgical mask. Today's census is four with no clients on hospice services.

LPA observed the presence of two (2) direct support professionals (DSP), one (1) registered nurse (RN), Assistant Administrator and one (1) respiratory therapist (RT). LPA observed (4) clients present in care. LPA was informed the day prior to visitation, C1 was transported for medical attention.

LPA and Assistant Administrator toured the interior of the facility including (5) private clients bedrooms, kitchen, (1) shared shower room, staff restroom, laundry room and common areas. LPA observed two clients to be sleeping during time of visit. LPA spoked with one client regarding the holiday seasons. LPA and C3 discussed C3's current concerns at the facility which is regarding the laundry room when washer is in use. LPA observed Administrator Certificate for Esperanza L. Sorongan #6014653735 to be active with expiration date of 01/15/2025. LPA observed the facility to be clean, safe, and in good repair. In areas toured, no immediate health, safety, personal rights violation was observed.

LPA and Assistant Administrator discussed DSP staffing shortage but LPA was informed shifts are being covered appropriately until staffing schedule returned to normal.

LPA conducted a file review of two clients and two personnel records and found the files to be complete. LPA completed the CARE inspection tool and found facility to be in compliance.

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: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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