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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803713
Report Date: 12/08/2023
Date Signed: 12/08/2023 04:06:42 PM

Document Has Been Signed on 12/08/2023 04:06 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:RUTHIE'S HOMEFACILITY NUMBER:
486803713
ADMINISTRATOR:ROBIN BRANDONFACILITY TYPE:
735
ADDRESS:3789 CLAY BANK RDTELEPHONE:
(707) 673-2047
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
12/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Raquel Cistac, AdminstratorTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Raquel Cistac, Administrator. There were no residents on site at the time of inspection. There was one staff member present. Administrator was off site at an appointment with a resident, one was in hospital, and one at Day Program.
LPA toured the facility, all exits were unobstructed, and the facility was found to be at a comfortable temperature of 68 F. Staff have current CPR/first aid certifications on file. 2 Fire extinguishers were charged and serviced on 07/21/2023. The facility has a supply of PPE. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. The kitchen was clean and well-organized. There was ample supply of perishable and non-perishable food as required by Title 22 regulation. Bedrooms were furnished with decor that reflects each resident; supplied with clean linens and ample storage for residents' belongings. The living room was decorated with a Christmas Tree and lots of little touches to make the facility homey. The backyard was free from debris and provided lots of space for activities. There were also chairs and a table for outside activities. The laundry room was locked and toxins and detergents were locked in cabinets. The garage was locked. It stored PPE, extra incontinence supplies and emergency water and supplies. Residents help with daily activities of the household, including planning and preparing meals and laundry.
Continued on 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
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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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: RUTHIE'S HOME
FACILITY NUMBER: 486803713
VISIT DATE: 12/08/2023
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Continued from 809

LPA requested the following updated forms to be submitted to Community Care Licensing by 01/01/2024:
· 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
· LIC 9020 Register of Facility Residents
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC809 (FAS) - (06/04)
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