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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801750
Report Date: 05/15/2024
Date Signed: 05/16/2024 08:17:39 AM

Document Has Been Signed on 05/16/2024 08:17 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:MIRACLE LANE HOUSEFACILITY NUMBER:
486801750
ADMINISTRATOR/
DIRECTOR:		PUNZALAN, ELPIDIOFACILITY TYPE:
735
ADDRESS:1625 FAIRFIELD AVE.TELEPHONE:
(707) 422-2906
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Marissa Gueco, House ManagerTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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 Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Required - 1 Year inspection and met with Marissa Gueco, House Manager/Administrator.
LPA toured the facility and observed all exits were unobstructed. The facility was clean, well-organized and found to be at a comfortable temperature.
Fire extinguisher was charged and serviced 05/01/2024. Carbon monoxide detector and smoke detectors are tested monthly, with the last test on 5/10/2024. Smoke detector was tested and observed operational. LPA observed a supply of PPE, linens (bedding, towels, etc.). Disinfectants/cleaning solutions (observed locked). Client bedrooms were furnished per regulation. Facility food supply was within regulation. Medication was centrally stored and locked in kitchen. Sharps and cleaning supplies locked beneath kitchen sink. 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 observed all required postings, including Administrators' Certificates for Elpidio and Ligaya Punzalan, which are in effect until 02/01/2025.

Exit interview conducted with House Manager/Administrator, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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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