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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803074
Report Date: 09/19/2023
Date Signed: 09/19/2023 02:35:19 PM

Document Has Been Signed on 09/19/2023 02:35 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:
09/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Ma.Nimpa Balderdara, House ManagerTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Jill Nakagawa, arrived unannounced to conduct an Annual Inspection and met with Ma. Nimpa Balderdara, House Manager. There were no residents at the time of inspection as they were all at Day Program or at work.

The facility was a comfortable temperature, free from obstructions and was well lit. Extra hygiene products and linens were available and grab bars were observed. Water temperature in residents' bathrooms was within acceptable range of 105 to 120 degrees F. Toxins are located in locked cabinets in the garage and under kitchen sink. Knives are locked in the kitchen. Medications were centrally stored and locked. Residents' cash resources were verified and in order. Perishable and non-perishable foods were sufficient.

Fire extinguishers located in the kitchen and laundry room were last inspected January 26, 2023 and fully charged. Smoke detectors located throughout the facility were tested and functional. Carbon monoxide detectors were observed and functional. Staff and resident records were reviewed and in order. Staff have required First Aid/CPR certificates.

Licensee/Administrator to submit updates of the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Liability Insurance and Surety Bond.

There were no deficiencies found at the time of inspection. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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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