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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801443
Report Date: 11/15/2022
Date Signed: 11/15/2022 11:14:29 AM


Document Has Been Signed on 11/15/2022 11:14 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:MASONIC GUEST HOMEFACILITY NUMBER:
486801443
ADMINISTRATOR:LACAP, LEONIDAFACILITY TYPE:
740
ADDRESS:310 MASONIC DR.TELEPHONE:
(707) 554-1432
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 4DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Leonida LacapTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Required - 1 Year inspection and met with Administrator Leonida Lacap. There were two (2) carestaff on site. The four (4) residents had just left for their Day Program. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

LPA toured facility and grounds with Administrator and observed COVID-19 precaution signs posted in common areas to promote hand washing and physical distancing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Infection control practices are present: entry procedures, face covering, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Staff clean and disinfect the facility 3 times or more if needed. Bathrooms are equipped with liquid soap and paper towels. Facility submitted a mitigation program plan, as well as the Infection Control Plan and Monkeypox Control Plan. Residents received their Flu vaccines at the facility yesterday.

In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. No accessible bodies of water or fire safety hazards observed. 2 Fire Extinguishers were found to be charged and serviced 09/21/22. 9 Smoke Detectors and 2 Carbon Monoxide Detectors were fully operational. There was sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations.

LPA requested the following updated documents to be submitted to CCLD by 11/28/22:
LIC500 (Personnel Report), the Resident Roster

Exit interview conducted with Administrator.
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: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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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