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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803251
Report Date: 06/29/2022
Date Signed: 06/29/2022 10:21:18 AM


Document Has Been Signed on 06/29/2022 10:21 AM - 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:MASONIC GUEST HOME IIFACILITY NUMBER:
486803251
ADMINISTRATOR:LACAP, LEONIDAFACILITY TYPE:
740
ADDRESS:108 PINTO DRIVETELEPHONE:
(707) 644-3822
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Leonida LecapTIME COMPLETED:
10:30 AM
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LPA Willis arrived unannounced to conduct an Annual Required inspection and met with Administrator, Leonida Lecap. This inspection is focused on the Covid protocols of this facility.

LPA observed that facility had Covid posters throughout the facility and had sufficient PPE supplies but was unable to complete inspection.

LPA will return to complete inspection at a later date.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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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