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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803693
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:06:55 PM

Document Has Been Signed on 12/10/2024 03:06 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WAYNE HOMEFACILITY NUMBER:
486803693
ADMINISTRATOR/
DIRECTOR:		DANICA EDNALAGAFACILITY TYPE:
740
ADDRESS:909 CALLE DEL CABALLOTELEPHONE:
(650) 703-1217
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Administrator, Danica Ednalaga
Licensee, Kevin Braud		TIME VISIT/
INSPECTION COMPLETED:
03:15 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
12/10/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently four (4) residents in care. Facility approved/cleared for four (4) non-ambulatory. LPA was greeted by Administrator, Danica Ednalaga. Licensee, Kevin Braud arrived later during visit. Two (2) out of four (4) residents were attending day program during visit.

At approximately 1:00pm, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. All refrigerated and dry foods were found to be stored in a safe manner being labeled and dated.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 116.4 and 115.8 which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 05/2024. Facility conducts monthly disaster and fire drills with the last one being conducted 11/21/2024. LPA observed all pathways and hallways to be free of obstruction. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to residents were located in the garage and laundry room and under the kitchen sink and found to be secured. Facility has a back up generator. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Cash resources were documented.

LPA conducted a review of four (4) resident records. All records had the required documentation.


continued on LIC809-C
Kimberley MotaTELEPHONE: (707) 588-5071
Anthony LoeraTELEPHONE: (707) 588-5026
DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WAYNE HOME
FACILITY NUMBER: 486803693
VISIT DATE: 12/10/2024
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
26
27
28
29
30
31
32
LPA conducted review of four (4) staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file. Facility conducts monthly training's for staff.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC400- Affidavit Regarding Client/Resident Cash Resources
Surety Bond
Liability Insurance

Exit interview conducted with Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2