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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803074
Report Date: 10/14/2024
Date Signed: 10/14/2024 09:45:57 PM

Document Has Been Signed on 10/14/2024 09:45 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/
DIRECTOR:		RONALDO S. PEREZFACILITY TYPE:
735
ADDRESS:6135 WILD DUNE COURTTELEPHONE:
(707) 561-0388
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Nimpa Baldedara, House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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On 10/24/2024, Licensing Program Analyst (LPA) Araceli Canela conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by House Manager, Nimpa Baldedara. Administrator, Ronaldo Perez was contacted and arrived a few minutes later. The facility is a one story home that currently provides care for 4 clients, of which 3 were out in the community at Day Programs and one client was observed arriving home with staff upon LPAs arrival.

LPA toured the facility with lead staff and the facility was found to be clean, organized and at a comfortable temperature, with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. There was a supply of hygiene products and paper products available for client use. All client bedrooms have lighting & appropriate furnishings.
Fire Extinguishers were found to be last charged and serviced on 1/11/2024. 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 within regulation of 105 and 120 degrees F. There was a sufficient supply of both perishable and nonperishable foods properly stored as required by Title 22 Regulations. LPA reviewed all client files and they were found complete and organized with all the required information. Staff files were reviewed and staff had the required health screening, cleared fingerprints, current 1st Aid & CPR expiring 1/12/2026 and training on file.

Medications and facility records are located in the kitchen with medications secured in designated cabinet. Toxins are stored locked with magnet locks throughout facility. Sharps are locked in kitchen cabinet.


Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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: BUENAVISTA HOME AT EAGLE RIDGE
FACILITY NUMBER: 486803074
VISIT DATE: 10/14/2024
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Facility has emergency food and water for clients incase of an emergency.

During inspection Administrator, Ronaldo Perez left to take a client to a doctors appointment and lead caregiver went over the report with LPA and signed.

No deficiencies cited during the inspection.

LPA requested the following documents be sent to CCL by COB 11/14/2024:

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)
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC809 (FAS) - (06/04)
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