486800888-2-14-2025-21-AS-SSTN-DDVSRQ-20250214130644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486800888
Report Date: 02/14/2025
Date Signed: 02/14/2025 01:06:58 PM

Document Has Been Signed on 02/14/2025 01:06 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 II		FACILITY NUMBER:	486800888
ADMINISTRATOR/ DIRECTOR:	VERANO, MATILDA		FACILITY TYPE:	740
ADDRESS:	1243 GRANADA ST.		TELEPHONE:	(707) 552-8550
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	02/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Matilde Verano - Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 9:15AM, Licensing Program Analysts (LPAs) Star Stevenson and Marisol Cuadra made an unannounced annual required inspection of this licensed senior care facility. At approximately 9:40AM Administrator Matilde Verano arrived. At approximately 9:45 AM, LPAs toured the building and grounds which was found to be clean and in good repair, warm and without odors. LPAs observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted in highly visible areas. Facility has the required 2 days of perishable and 72 hours of non-perishable food. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105- and 120-degrees F at faucets accessible to residents. Covered trash cans and paper towels were observed in the bathrooms, as well as, extra PPE, and incontinence supplies. Fire extinguishers were inspected and were last charged on 01/2025. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present and working. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. LPAs observed both a bed and couch in the garage with pillows that could make it possible for a staff person or other persons to sleep in the garage. A conversation was held with Administrator Matilde Verano that the bed needs to be removed or stored in a manner that does not allow for persons sleeping there. (Technical Violation was issued) Licensee agrees to submit pictures of the sleeping area removed or stored in such a manner that discourages sleeping. At approximately 10:45AM, LPAs reviewed 5 of 6 resident records and found 5 of 6 residents were in good order including medical assessments and careplans were current as stated by regulation. LPAs reviewed 3 of 6 medication records are thorough, locked and centrally stored and contained physician's orders for each resident. one (1) of six (6) residents are receiving Hospice services and the Hospice care plans were up to date for each resident. Continue on LIC809C

Kimberley Mota	TELEPHONE: (707) 588-5051
Star Stevenson	TELEPHONE: 707-588-5081
	DATE: 02/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

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: 02/14/2025

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At approximately 11:30 PM, LPAs reviewed 5 of 8 staff records. 5 of 8 staff records had required documents, TB clearance and current 1st aide/CPR certifications

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC610E- Disaster Plan
Evidence of updated Liability Insurance
Updated copy of DEED
Updated LIC308 (designation of responsibility)

No citations were issued during today’s visit.
Exit interview conducted with Administrator Matilde Verano and a copy of this report was given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Star Stevenson	TELEPHONE: 707-588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

LIC809 (FAS) - (06/04)

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