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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801892
Report Date: 10/16/2023
Date Signed: 10/16/2023 12:51:33 PM


Document Has Been Signed on 10/16/2023 12:51 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:BENICIA LOVING CARE HOMEFACILITY NUMBER:
486801892
ADMINISTRATOR:GULAPA, LUCITAFACILITY TYPE:
740
ADDRESS:948 ROSE DRIVETELEPHONE:
(707) 748-1688
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY:6CENSUS: DATE:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Maria Corazon-Datario, CaregiverTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived at this facility unannounced, to conduct an Annual Required lnspection. Benicia Loving Care currently has 6 residents, 4 of whom are receiving hospice care. There were 2 care staff at the time of inspection.

LPA arrived at the facility and had temperature checked and health questions asked. Masks are requested to be worn prior to entry. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged and inspected within the last 12 months. Toxins are stored and not accessible. There was a supply of hygiene products and paper products available for resident use. Facility has a large supply of extra linens.

Facility has required posters in place at the entrance and throughout the building. The entrance area has a small table with hand sanitizer, thermometer and other items designated for visitors and staff before coming into work or visit. Facility has plenty of PPE supplies. Medications are secure and not accessible to residents. Facility has a 30-day supply of medication.

Grounds were well-kept and free of debris, and provided plenty of outdoor seating for residents and visitors to enjoy. Facility was getting a new roof at the time of visit.

There were no deficiencies found in the areas inspected.


No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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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