<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803285
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:34:33 PM


Document Has Been Signed on 09/20/2024 03:34 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:C & F SENIOR CARE HOMEFACILITY NUMBER:
486803285
ADMINISTRATOR:FOJAS, LINAFACILITY TYPE:
740
ADDRESS:1120 SONGWOOD ROADTELEPHONE:
(707) 246-0867
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Lina Fojas, Administrator/LicenseeTIME COMPLETED:
03:46 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, Administrator, Lina Fojas. There are currently 5 residents in care. This facility is licensed for non ambulatory residents, with hospice waiver approved for 3 of the residents.

LPA toured the home and found the home organized, clean and at a comfortable temperature with all exits free from obstruction. This home is a two level home and all the resident bedrooms are located on the first level of the home. Residents have a working call button to alert staff. Exit doors have auditory alarms to alert staff. Smoke detectors and carbon monoxide detectors were tested and operational. The fire extinguisher located in the kitchen was observed charged and serviced on 6/21/2024. Fire drill was conducted by the facility and documented on 7/1/2024. Water temperature in the resident bathroom was tested and found to be within appropriate range of 105-120 degrees. Bathrooms have required non-skid surfaces and grab bars. Cleaning products and knives are stored in locked cabinets in the kitchen.

There was a 7 day supply of non-perishable foods. There are adequate dishes, glasses and silverware. Residents' medications are stored in kitchen locked cabinet. Resident and staff files are located and locked in closet. Staff have the required training, Health screen and proof of CPR/1st aid that expires 2025 and 2026. Resident files reviewed were found complete and organized. Administrator certificate for Lina Fojas #6006130740 expires 10/5/2025.

Licensee/Administrator to submit the current following documents by 10/15/2024:
· LIC 500 Personnel Report
· LIC 9020 Register of Facility Residents
Copy of Liability Insurance

No citations issued during todays inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1