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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800888
Report Date: 05/20/2024
Date Signed: 05/20/2024 03:50:00 PM


Document Has Been Signed on 05/20/2024 03:50 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:MED RESIDENTIAL CARE HOME IIFACILITY NUMBER:
486800888
ADMINISTRATOR:VERANO, MATILDAFACILITY TYPE:
740
ADDRESS:1243 GRANADA ST.TELEPHONE:
(707) 552-8550
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:6CENSUS: DATE:
05/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Matilda Verano, AdministratorTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management inspection and met with Matilda Verano, Administrator.

LPA is following up regarding resident, R1 who recently passed away but was not on hospice. LPA reviewed documents and spoke with Administrator who provided a timeline of events. Administrator has agreed to provide LPA a copy of the death certificate once it is available.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
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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