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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004650
Report Date: 03/12/2024
Date Signed: 03/12/2024 04:56:53 PM

Document Has Been Signed on 03/12/2024 04:56 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:BUENA VISTA HOME IIFACILITY NUMBER:
347004650
ADMINISTRATOR:ASTRONOMO, REYFACILITY TYPE:
735
ADDRESS:6350 MARIPOSA AVENUETELEPHONE:
(916) 727-7273
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 4CENSUS: 4DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Melody Bulanadi, Co-Administrator/caregiver TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Melody Bulanadi, Co-Administrator/caregiver, and explained purpose of inspection. Also present was Edgar Bulanadi, staff. LPA was advised that Administrator, Rey Astronomo, was currently out of the facility. The facility is a level 4--I home, vendorized by Alta California Regional Center, and is licensed for (4) clients. LPA observed (1) client present in the common area and (3) clients resting in their rooms after returning from day program at the start of the inspection.

LPA and Co-Administrator toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms, (1) staff room, (2) resident bathrooms, kitchen, laundry area and garage. LPA observed the facility to be clean, in good repair and odor-free. Each bathroom has the necessary grab bars, non-skid flooring, paper towels, trash can with lids and 20-second hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food and sharps, toxins and medications to be locked in the kitchen. There is additional food/supplies in the garage. The inside temperature measured 69*F, and the hot water measured 105*F in the kitchen. There is a complete first aid kit and the fire extinguisher was last serviced 9/1/23. There is (1) unlocked exit gate and outdoor seating area.

LPA reviewed (2) of (4) client files and found them to contain current documentation. LPA reviewed P&I funds and records for (2) clients, and there were no discrepancies noted. Medications were reviewed for (2) clients. There are orders on file for medications being administered, and the medication records were organized and current. LPA reviewed (6) staff files which were not initially at the location. LPA found the files to be organized and contain all required paperwork and current documentation of training, including First Aid and CPR. Staff ongoing training was conducted in November 2023. All staff are cleared and associated to the facility. The Infection Control Plan was last reviewed March 2023. LPA to follow up with the Administrator if an age exception request is needed at this time. LPA requested an updated copy of the LIC308, LIC500 and Surety bond documentation be sent to CCLD by 3/19/24. Exit interview. There are no citations issued during today's inspection.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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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