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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803074
Report Date: 10/21/2022
Date Signed: 10/21/2022 12:18:46 PM

Document Has Been Signed on 10/21/2022 12:18 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:BUENAVISTA HOME AT EAGLE RIDGEFACILITY NUMBER:
486803074
ADMINISTRATOR:RONALDO S. PEREZFACILITY TYPE:
735
ADDRESS:6135 WILD DUNE COURTTELEPHONE:
(707) 561-0388
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Ronaldo Perez, AdministratorTIME COMPLETED:
12:30 PM
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On 10/21/2022, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by staff, Nimpa Baldedara. Administrator, Ronaldo Perez was contacted and arrived for the inspection. The facility is a 6 bed one story home that currently provides care for 4 clients, all of which were out in the community at Day Programs or workplaces at the time of visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator and staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 1/28/2022 at the time of the visit. Smoke and carbon monoxide detectors were found throughout the facility tested and found to be in working order. Water was tested at faucets accessible to clients and found to be measured between 113.7 and 115.3 degrees F which is within regulation between 105 and 120 degrees F. There was a sufficient supply of both perishable and nonperishable foods properly stored as required by Title 22 Regulations with balanced meals and alternative meal options for clients. LPA conducted a sample file review and found all reviewed staff to have current 1st Aid & CPR training certification on file.

Medications and facility records are located in the kitchen with medications secured in designated cabinet. Toxins are stored in a locked facility laundry room which were found to be secured upon observation. There was a supply of hygiene products and paper products available for client use. All client bedrooms have lighting & appropriate furnishings.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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: BUENAVISTA HOME AT EAGLE RIDGE
FACILITY NUMBER: 486803074
VISIT DATE: 10/21/2022
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Infection Control:
Facility has submitted an Infection Control Plan to CCLD for review. All clients and staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and clients ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature daily and based on change of condition.

No deficiencies cited during the inspection.

LPA requested the following documents be sent to CCL by COB 11/4/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC809 (FAS) - (06/04)
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