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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803334
Report Date: 04/03/2023
Date Signed: 04/03/2023 11:10:56 AM

Document Has Been Signed on 04/03/2023 11:10 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:AGING LOVELYFACILITY NUMBER:
486803334
ADMINISTRATOR:ALVIS, HIGINIAFACILITY TYPE:
735
ADDRESS:1148 HAYES STREETTELEPHONE:
(707) 421-1665
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 0DATE:
04/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Alejandra Arciga, DSPTIME COMPLETED:
11:21 AM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced at Aging Lovely for the purpose of conducting a Required - 1 Year inspection. LPA met with Direct Support Professional (DSP) Alejandra Arciga. Administrator Higinia Alvis was not available during time of visit.

LPA toured the facility. Currently, the facility does not have clients in care; last date clients were in the home was on 02/15/2022. Fire extinguisher was charged and serviced on 07/29/2022.

LPA requested the following updated records to be submitted to Community Care Licensing by 05/03/2023:
    · LIC 308 Designation of Facility Responsibility
    · LIC 500 Personnel Report
    · LIC 610D Emergency Disaster Plan
    · LIC 400 Affidavit Regarding Client/Resident Cash Resources
    · LIC 402 Surety Bond
    · Copy of current Administrator's Certificate

Exit interview conducted with staff Alejandra Arciga, whose signature on this document confirms receipt. LPA emailed a copy of this report directly to Administrator

No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
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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