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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801443
Report Date: 08/09/2024
Date Signed: 08/12/2024 07:22:10 AM


Document Has Been Signed on 08/12/2024 07:22 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: 6DATE:
08/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:27 PM
MET WITH:Leni Lacap, Licensee/AdministratorTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Canela arrived unannounced and met with Leni Lacap, Licensee/Administrator.

During the course of a complaint investigation, LPA discovered Resident R1 who is diagnosed with Dementia did not have a current Medical Assessment as required. The last medical Assessment was noted as being done on 1/28/2023 and more than a year. R1 did not have a current resident appraisal in file and the last one done was completed, over a year, on 1/24/2023. During todays visit LPA observed 3 twin size mattress/box spring in the backyard and they need to be removed. Facility stated they had placed the extra mattress out to disinfect. LPA also observed several garbage bags on top of a table in the backyard that contained resident R2's clothing and were said to have been washed and put in bags since resident was positive for Covid and they wanted to disinfect the room before they bring the clothes in. LPA requested facility to bring the bags of clothing in as this may be a personal rights violation. LPA consulted with facility regarding some flat electric hair irons that were taken from resident R3 and facility was requested to return items back to resident.

Due to computer issues and time restraint, LPA will need to return to issue any citations or advisory notes, from todays visit.

No citations issued
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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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