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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802064
Report Date: 05/21/2024
Date Signed: 05/21/2024 02:24:24 PM


Document Has Been Signed on 05/21/2024 02:24 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:COMFORT LIVING FOR SENIORS IIFACILITY NUMBER:
486802064
ADMINISTRATOR:SADDI, DONABELL W.FACILITY TYPE:
740
ADDRESS:685 PURPLE MARTIN DRIVETELEPHONE:
(707) 410-9706
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 6DATE:
05/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Donabell Saddi, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced for the purpose of reviewing the physical plant for capacity increase. LPA was greeted by caregiver, who contacted Administrator, Donabell Saddi, who arrived shortly.

LPA toured the facility, including the bedroom involved in the capacity increase. Licensee is requesting capacity increase from 6 to 7. Currently resident R1 is using alternative furnishings but according to regulation R1 must have access to a bed as well as the alternative furnishing. Administrator will discuss with family.
All other bedrooms were found to have required furnishings and had an ample supply of linens. The facility was clean and staff was attentive to residents' needs.

No deficiencies noted at the time of this visit in the areas toured by LPA.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
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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