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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800768
Report Date: 07/11/2023
Date Signed: 07/11/2023 03:10:25 PM

Document Has Been Signed on 07/11/2023 03:10 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 4DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Virginia Punzalan, co-administratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Karina Canela arrived for the purpose of conducting a Required -1 Year inspection and met with Virginia Punzalan, back-up administrator. Patricia Bucal, Facility Manager, and Ermelynn Goco, Live-in DSP, were also present.
LPA toured the facility, all exits were unobstructed. The facility was found to be clean & at a comfortable temperature. LPA observed a supply of linens and cleaning solutions (observed locked & inaccessible). Hand soap and paper towels are available in bathrooms. Facility food supply was within regulation and accessible to clients. Medication was centrally stored. Water temperature was tested and observed between 105 to 120 degrees F.
Fire extinguisher was charged and serviced 05/02/2023. Smoke detectors & carbon monoxide detector observed operational. LPA reviewed staff and clients records. Staff have current training certifications in First Aid & Cardiopulmonary Resuscitation (CPR) in file.

LPA requested the following updated forms to be submitted to Community Care Licensing by 08/11/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Surety Bond
· LIC 9020 Facility Register of Client/Residents
· LIC 610D Emergency Disaster Plan
· Copy of current Administrator's Certificate

Exit interview conducted with co-administrator, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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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