486803678-10-18-2024-21-AS-ACAA-DA6UAC-20241018152431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803678
Report Date: 10/18/2024
Date Signed: 10/18/2024 03:26:11 PM

Document Has Been Signed on 10/18/2024 03:26 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:	GOLD COAST CARE HOME		FACILITY NUMBER:	486803678
ADMINISTRATOR:	LOMBOY, RUSTOM NEIL		FACILITY TYPE:	740
ADDRESS:	443 OLD RIVER DRIVE		TELEPHONE:	(707) 631-8946
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	6	CENSUS: 6	DATE:	10/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Neil Lomboy, Administrator		TIME COMPLETED:	03:30 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 conducted an unannounced Annual Required – 1 yr. inspection for this facility and met with Administrator, Neil Lomboy. The facility currently provides care for 6 non-ambulatory residents, one of whom is receiving Hospice services. There were 2 additional care staff on site at the time of inspection. LPA arrived at the facility and began the facility tour with staff, Alex Ordonez and Administrator arrived a few minutes later. Facility was at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged and serviced on 03/28/2024. Smoke and carbon monoxide detectors were tested and found to be in working order. Last emergency drill was conducted and documented by facility on 7/21/2024. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility also has extra food in a cabinet in the garage. Toxins are stored in a locked cabinet in the facility garage and under bathroom and kitchen sinks and found to be secured. There was a supply of hygiene products and paper products available for resident use. All residents bedrooms have lighting & appropriate furnishings. Water temperature was measured at faucets accessible to residents and was measured between required regulation of 105 and 120 degrees F. LPA reviewed 6 resident files and they were found complete. LPA reviewed medication with administrator. Care staff have current CPR and 1st Aid training on file and the required training. Administrator certificate for Neil Lomboy, #6040644740 expired 6/6/2024 and it was renewed and waiting for new certificate. LPA observed live-in staff bedroom to be locked and secured. LPA went over the complaint poster PUB475 the facility has in the wall needing to be size 20X26 and administrator will post the correct size and notify LPA. 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: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

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: GOLD COAST CARE HOME	FACILITY NUMBER: 486803678
	VISIT DATE: 10/18/2024

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Facility informed LPA they have qualified for a Community Care Expansion Grant and will be receiving some renovations including flooring, bathroom upgrades and kitchen cabinets. LPA and Administrator went over facilities responsibility to notify CCL with a written plan regarding the renovations being done, expected time of completion and safety measures taken to insure the health and safety of residents in care during the renovation.

LPA requested the following documents be sent to CCL by 11/15/24:

LIC 9020 Register of residents
LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
Copy of Certificate of Liability Insurance
Lease Agreement

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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