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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803709
Report Date: 05/10/2024
Date Signed: 05/10/2024 12:13:16 PM

Document Has Been Signed on 05/10/2024 12:13 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:NANAY HOME LLCFACILITY NUMBER:
486803709
ADMINISTRATOR/
DIRECTOR:
LEILANI JOCSONFACILITY TYPE:
735
ADDRESS:369 BISHOP DRIVETELEPHONE:
7079995267
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: DATE:
05/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:04 AM
MET WITH:Leilani Jocson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:25 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
At approximately 8:50AM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced Annual Required inspection to this facility and met with Leilani Jocson, Administrator and licensee Kevin Braud arrived shortly after. At approximately 9:05AM, LPA and Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secure and not accessible to clients. Medication is centrally stored and secure. There is a sufficient supply of hygiene products and linens on hand for client use. Four out four clients rooms were inspected and found to be within regulation. Each of clients room is decorated and color coordinated to clients preference and personality. All linens and towels are color coordinated based on clients preferences. Mattress pads were in place or available for Client use. Advised administrator and licensee Night lights shall be maintained in hallways and non-private bathrooms. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. Smoke detectors and carbon monoxide detectors are inter connected and seven out of seven smoke/carbon monoxide detectors were tested and found to be in working order. Two out of two fire extinguishers were fully charged and inspected on 9/20/2023. Fire sprinklers are located throughout the facility. Disaster Drills are conducted monthly with the last drill conducted 4/8/2024.


At approximately 10:10AM, LPA reviewed 4 of 4 Client records and 4 of 17 Staff records, which were all found to be well organized, thorough and contained the required documentation. First aid and CPR certification were current in staff files reviewed. P&I monies were documented, secure and not commingled. Administrator's Certificate is expired. Administrator, Leilani Jocson provided proof to LPA of recertification submission and course completion as well as letter requesting update of recertification processing.

No deficiencies were observed in the areas inspected. No citations issued during today’s visit


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

Updated copies of the following documents were received during visit update facility file:
LIC610D- Disaster Plan
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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 1