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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480107184
Report Date: 04/16/2024
Date Signed: 04/16/2024 12:36:53 PM

Document Has Been Signed on 04/16/2024 12:36 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:DELTA MEADOWS CARE HOMEFACILITY NUMBER:
480107184
ADMINISTRATOR/
DIRECTOR:
CECILIA GANZONFACILITY TYPE:
740
ADDRESS:101 O'BRIEN CIRCLETELEPHONE:
(707) 647-1759
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 5CENSUS: 5DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Cecilia GanzonTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Administrator Cecilia Ganzon.

This facility has a fire clearance for five non-ambulatory residents. There are three private and one shared resident rooms. Three resident rooms have exits to the outside. There is one shower that is between two half bathrooms. LPA toured the common areas and resident rooms. There is an ample supply of perishable and nonperishable food. There is a locked cabinet for medications and confidential folders.

A couple of topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by May 1, 2024:
-LIC 308 designation of administrative responsibility
-liability insurance
-LIC 500 facility personnel or staff schedule
-transportation procedures for residents
-plan for incidental and medical care for residents

LPA reviewed two resident records and the staff records.

no deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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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