486803251-6-21-2023-21-AS-ACAA-CSZPZ8-20230621114508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803251
Report Date: 06/20/2023
Date Signed: 06/21/2023 11:45:21 AM

Document Has Been Signed on 06/21/2023 11:45 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 II		FACILITY NUMBER:	486803251
ADMINISTRATOR:	LACAP, LEONIDA		FACILITY TYPE:	740
ADDRESS:	108 PINTO DRIVE		TELEPHONE:	(707) 644-3822
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	06/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Leonida Lacap		TIME COMPLETED:	04:27 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, care staff, Jocelyn Bernardo. Administrator, Leonida Lacap was called and arrived a few minutes later. This facility is licensed for a total of 6 non-ambulatory residents and no approval for bedridden. There are currently 5 residents living in the home and the facility has a Hospice waiver approved for 2 of the residents. Currently there are no residents receiving hospice services. LPA toured facility and grounds and observed facility was found to be clean at a comfortable temperature. Facility has at least two days of perishable and one week of non-perishable foods. Fire Extinguisher was found to be charged, and serviced 9/21/2022. Smoke alarms and carbon monoxide detector were operational during the inspection.Water temperature in bathrooms measured at 107 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Resident bedrooms are furnished per regulation, but 2 out of 5 resident beds did not have the required linens and LPA consulted and went over requirements with administrator. LPA went over daily activities for residents. LPA reviewed all resident files, and some staff files. Medication is centrally stored and locked in closet/cabinet. Facility uses the centrally store log and residents medication is organized in a container, labeled with individuals name. Administrator Certificate for Administrator,Leonida Lacap #6006612735 expires 10/14/2023. Staff training was reviewed and CPR/1st Aid for staff, Jocelyn Bernardo expires 1/28/2025. Continue report see LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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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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: MASONIC GUEST HOME II	FACILITY NUMBER: 486803251
	VISIT DATE: 06/20/2023

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LPA discussed the Emergency Disaster Plan and Infection Control Plan. Facility understands the side yard gates may not be locked and will need to request approval of locked perimeter prior to locking- if they choose to lock the gates. LPA went over master bedroom bathroom that may only be used by the residents occupying the bedroom, no other resident or staff may use that bathroom.

Licensee/Administrator to submit the current following documents by 7/20/2023:

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of Liability Insurance
Copy of current Lease Agreement
Current facility sketch- identifying rooms used by staff or residents, and the size of the room

No citations issued during todays inspection.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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