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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920076
Report Date: 10/17/2024
Date Signed: 10/17/2024 03:44:26 PM

Document Has Been Signed on 10/17/2024 03:44 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: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: 3DATE:
10/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Staff - Benilda CastilloTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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On 10/17/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit. LPA spoke with Administrator Romano Dumuk via phone to explain the purpose of the visit. Administrator was unable to make it to the facility and gave staff Benilda Castillo permission to sign the report.

The purpose of the visit is to gather more information regarding a death report Community Care Licensing (CCL) received on 09/27/24. LPA spoke with the administrator and facility staff regarding the events leading up to R1s death. Death report states that R1 passed away in the hospital after being sent out due to increased heart rate.

LPA obtained a copy of R1's LIC602 and ID page.

At this time, no deficiencies are cited.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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