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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920076
Report Date: 08/08/2024
Date Signed: 08/08/2024 10:23:42 AM

Document Has Been Signed on 08/08/2024 10:23 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:JONATHAN VILLAFACILITY NUMBER:
345920076
ADMINISTRATOR/
DIRECTOR:		DUMUK, ROMANOFACILITY TYPE:
735
ADDRESS:7728 BLACK SAND WAYTELEPHONE:
(650) 703-1217
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 4DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrator- Romano & Ivy DumukTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 08/08/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required 1- year annual inspection utilizing the care tool. LPA met with Administrator Romano Dumuk and Ivy Dumuk and explained the purpose of the visit.

Administrator and LPA conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to four (4) resident bedrooms, two (2) bathroom, kitchen, garage, common areas and backyard.
LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. The temperature in the facility was 72 degrees. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed the fire extinguisher, located near the kitchen, which was last inspected on 07/22/24. LPA reviewed drill logs, which are conducted monthly. LPA observed required Licensing posters posted throughout the facility.

LPA reviewed four (4) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for two (2) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of three (3) staff record. Staff has training in infection control, first aid and CPR, and other various areas of care provision.

No deficiencies are being cited during today's inspection.

Exit interview conducted and copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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