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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800768
Report Date: 11/16/2021
Date Signed: 11/16/2021 11:52:41 AM

Document Has Been Signed on 11/16/2021 11:52 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PENNSYLVANIA CARE HOMEFACILITY NUMBER:
486800768
ADMINISTRATOR:PUNZALAN, ELPIDIOFACILITY TYPE:
735
ADDRESS:2055 PENNSYLVANIA AVENUETELEPHONE:
(707) 438-0267
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
11/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Virginia Punzalan, Co-AdministratorTIME COMPLETED:
12:01 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced at Pennsylvania Care Home and met with DSP staff Tony Legaspi. Co-Administrator Virginia Punzalan arrived later. The purpose of this case management inspection is to follow up on an incident which was self reported by phone and an incident report was received by Community Care Licensing (CCL) on 11/15/2021.
The following was reported: On 11/11/2021 at approximately 7:14 PM Client (C1) left the facility to the nearby store to buy something and meet with friends. C1 did not return on 11/11/2021 to the facility, but staff stated C1 would sometimes spend the night at a friend's home. Staff (S1) was going to contact law enforcement the following day when two police officers arrived to the home to inform the facility of an incident that occurred which resulted in C1 being fatally shot. C1's responsible party, North Bay Regional Center Service Coordinator, and CCL were notified of the incident.


During today's inspection LPA requested and obtained copies of documents for Client (C1) and other clients in the home (C2, C3, C4).

Exit interview was conducted with Co-Administrator Virginia Punzalan whose signature below confirms receipt of report.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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