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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480110447
Report Date: 04/17/2024
Date Signed: 04/17/2024 09:03:06 AM

Document Has Been Signed on 04/17/2024 09:03 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:DELGADO ADULT RESIDENTIAL HOMEFACILITY NUMBER:
480110447
ADMINISTRATOR/
DIRECTOR:		KAMAL RAIFACILITY TYPE:
735
ADDRESS:123 ZINNIA CIRCLETELEPHONE:
(707) 647-0941
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 2DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Mahindra RaiTIME VISIT/
INSPECTION COMPLETED:
09:10 AM
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LPA Hiratsuka conducted this unannounced annual visit.

This facility has a fire clearance for six ambulatory residents. There are currently only two residents. This facility has four resident rooms. There is a locked shed in the backyard. There is an ample supply of perishable and nonperishable food. The common areas and resident rooms were inspected. LPA reviewed two resident files and the staff files.

The following shall be updated and submitted to Community Care Licensing Division by May 2, 2024:
-LIC 308 designation of administrative responsibility
-liability insurance
-LIC 500 facility personnel or staff schedule
-current surety bond
-copy of the theft and loss policy



no deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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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