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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800888
Report Date: 02/10/2024
Date Signed: 02/10/2024 05:34:32 PM


Document Has Been Signed on 02/10/2024 05:34 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: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: 6DATE:
02/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:11 PM
MET WITH:Caregiver and AdministratorTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility on 02/10/2024 to conduct a required annual inspection utilizing the full CARE inspection tool. LPA met with Caregiver who contacted Administrator who arrived to the facility shortly afterwards. LPA explained the purpose of the visit to Caregiver and Administrator.

Facility has six residents in care with two residents on hospice services. Facility is licensed for six nonambulatory residents, bedridden clearance for one and hospice waiver approved for one. Based on file review, LPA observed facility has an approved hospice waiver for two. LPA informed Administrator LPA will update facility license and mail to the facility once generated.

During today's inspection, LPA and Administrator conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: five resident rooms, bathroom, garage, kitchen, backyard and the common areas. LPA observed the facility to have adequate supply of linens and perishable and non perishable foods. LPA observed knives, medications and toxins to be locked and secured. In areas toured no immediate health, safety, personal rights violation was observed.

LPA and Administrator discussed Fire Marshall's upcoming inspection, LPA informed Administrator to inquire for bedridden clearance for two in Room #1.

Please continue to LIC 809-C...
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (279) 300-5157
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MED RESIDENTIAL CARE HOME II
FACILITY NUMBER: 486800888
VISIT DATE: 02/10/2024
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**LIC 809-C**

LPA conducted a file review for R1, R2, S1 and S2. LPA observed the required documents present on file. LPA and Administrator completed the CARE inspection tool and found the facility to be in compliance. No deficiencies observed.

At this time, LPA is requesting LIC 500, liability insurance and facility sketch for bedridden to be submitted to LPA Yang by Friday February 16, 2024.

Exit interview conducted and a copy of the report and Health Safety Code 1569.625 Staff training; legislative findings; contents will be emailed to Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (279) 300-5157
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
LIC809 (FAS) - (06/04)
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