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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801831
Report Date: 09/16/2024
Date Signed: 09/18/2024 10:42:05 AM


Document Has Been Signed on 09/18/2024 10:42 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:BENICIA ANGEL'S HOME 1, INC.FACILITY NUMBER:
486801831
ADMINISTRATOR:BAYON, EVELYNFACILITY TYPE:
740
ADDRESS:458 MILLS DRIVETELEPHONE:
(707) 748-0482
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY:6CENSUS: 5DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Erika De La Paz, Care staffTIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Araceli Canela made an unannounced annual required 1 Year inspection of this licensed senior care facility. LPA met with care staff, Erika De La Paz; Evelyn Bayon Licensee/Administrator was present in the facility but ill and was only able to speak to LPA by phone.

This facility is licensed for 6 non-ambulatory residents with a Hospice Waiver to allow 2 of the resident to be on Hospice. This facility does not have approval for bedridden and understands they do not have approval for a locked perimeter.

LPA initiated a tour of the facility and made the following observations: Facility was clean, organized and at a comfortable temperature, with passageways free from obstructions. Residents rooms were furnished per regulation. Water temperature in bathrooms used by residents measured within the required range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cleaning supplies and sharps are locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility maintains emergency food and water supplies.
Fire extinguishers were fully charged and last serviced May 14, 2024. Smoke and Carbon Monoxide detectors located throughout the facility were operational.

Administrator Certificate for Evelyn Bayon, #6780740018 expires on 10/5/2024. Staff have First Aid and CPR certificates and training. LPA reviewed all resident files and contained all records. Three staff files were reviewed and had the required training and proof of CPR/1st aid. Medication records were reviewed and facility needs to ensure the centrally stored log is fully completed at all times. LPA reviewed medication.

Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BENICIA ANGEL'S HOME 1, INC.
FACILITY NUMBER: 486801831
VISIT DATE: 09/16/2024
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/14/2024:

LIC500- Personnel Report
LIC9020- Register of residents
Evidence of Liability Insurance
Copy of current Administrator Certificate

No deficiencies cited during todays visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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