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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803709
Report Date: 05/25/2023
Date Signed: 05/25/2023 05:29:05 PM

Document Has Been Signed on 05/25/2023 05:29 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:NANAY HOME LLCFACILITY NUMBER:
486803709
ADMINISTRATOR:LEILANI JOCSONFACILITY TYPE:
735
ADDRESS:369 BISHOP DRIVETELEPHONE:
(707) 999-5267
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 4DATE:
05/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Leilani Jocson, AdministratorTIME COMPLETED:
05:43 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Leilani Jocson, Administrator.
LPA toured the facility and observed all exits were unobstructed. The facility was found to be clean & at a comfortable temperature; screening station was observed at front entrance.
2 of 2 fire extinguishers were charged and serviced 09/06/2022. There are 7 hardwired combination smoke and carbon monoxide detectors, which were tested & observed operational. LPA observed a supply of PPE, emergency food/supplies, linens (bedding, towels, etc.), and disinfectants/cleaning solutions (observed locked & inaccessible). Liquid hand soap and paper towels are available in 2 of 2 bathrooms. 4 of 4 client bedrooms were furnished per regulation. Facility food supply was within regulation and accessible to clients. Medication was centrally stored and locked. Client P & I Funds are locked and not commingled.

LPA requested the following updated forms to be submitted to Community Care Licensing by 06/26/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Surety Bond
· LIC 610D Emergency Disaster Plan
· Copy of current Administrator's Certificate

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2023
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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