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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801750
Report Date: 05/26/2023
Date Signed: 05/26/2023 05:05:52 PM

Document Has Been Signed on 05/26/2023 05:05 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MIRACLE LANE HOUSEFACILITY NUMBER:
486801750
ADMINISTRATOR:PUNZALAN, ELPIDIOFACILITY TYPE:
735
ADDRESS:1625 FAIRFIELD AVE.TELEPHONE:
(707) 422-2906
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
05/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Marissa Gueco, House ManagerTIME COMPLETED:
05:17 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Marissa Gueco, House Manager.
LPA toured the facility and observed all exits were unobstructed. The facility was found to be at a comfortable temperature.
Fire extinguisher was charged and serviced 05/02/2023. Carbon monoxide detector was tested and observed operational. LPA observed a supply of PPE, linens (bedding, towels, etc.), and disinfectants/cleaning solutions (observed locked). Client bedrooms were furnished per regulation. Facility food supply was within regulation. Medication was centrally stored and locked. LPA reviewed staff and client records. Staff have current training certifications in First Aid & Cardiopulmonary Resuscitation (CPR) in file. Client's records are up-to-date. P&I cash resources for clients were locked and not commingled. Water temperature was tested and was within regulation of 105-120 degrees F.

LPA requested the following updated forms to be submitted to Community Care Licensing by 06/26/2023:
    · LIC 308 Designation of Facility Responsibility (1 person per form)
    · LIC 500 Personnel Report
    · LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
    · Copy of Surety Bond
    · LIC 610D Emergency Disaster Plan
    · Copy of current Administrator's Certificate


Exit interview conducted with House Manager, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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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