<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801479
Report Date: 04/17/2024
Date Signed: 04/17/2024 03:58:02 PM


Document Has Been Signed on 04/17/2024 03:58 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:EXCEL CAREFACILITY NUMBER:
486801479
ADMINISTRATOR:MANIO, JESUS & ESPERANZAFACILITY TYPE:
740
ADDRESS:1728 SERENO DRIVETELEPHONE:
(707) 644-6799
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 3DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Jesus ManioTIME COMPLETED:
04:10 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
LPA Hiratsuka conducted this unannounced annual visit.

This facility has a fire clearance for six non-ambulatory. There are currently three residents in care. All resident rooms and common areas were inspected. The backyard was inspected. There is a pool in the backyard that has a fence and is locked. There are several locked sheds in the backyard. Three resident records and staff files were reviewed.

Several topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by May 3, 2024:
-LIC 308 designation of administrative responsibility
-liability insurance
-LIC 500 facility personnel or staff schedule

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1