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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803740
Report Date: 04/18/2023
Date Signed: 04/18/2023 01:53:28 PM

Document Has Been Signed on 04/18/2023 01:53 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:KALUSUGAN HOMES - BOXWOODFACILITY NUMBER:
486803740
ADMINISTRATOR:LEWIS-BARRETO, ANNABELLEFACILITY TYPE:
735
ADDRESS:2592 BOXWOOD LANETELEPHONE:
(707) 439-1816
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Alicia Valtierra Vazquez, Lead DSPTIME COMPLETED:
02:03 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Required - 1 Year inspection at this Adult Residential Facility and met with Alicia Valtierra Vazquez, Lead Direct Support Professional (DSP).
LPA toured the facility and observed all exits were unobstructed. The facility was found to be clean, sanitary, in good repair, and at a comfortable temperature. Staff and client records were reviewed; Staff have current CPR/first aid certifications in file. 2 fire extinguishers was charged and serviced 03/09/2023. 4 smoke detectors and 1 combination carbon monoxide/smoke detector were tested and observed operational. LPA observed client bedrooms are fully furnished per regulation. Liquid hand soap and paper towels were available in 2 of 2 bathrooms. Facility food supply was within regulation. P & I funds were secured and not commingled. Medication was observed locked and inaccessible to clients in care. Detergent and cleaning supplies were observed locked in the garage.

LPA requested the following updated forms to be submitted to Community Care Licensing by 05/18/2023:
· 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
· LIC 9020 Register of Facility Clients
· Copy of current Administrator's Certificate

Exit interview conducted with DSP, 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: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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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