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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803775
Report Date: 01/13/2022
Date Signed: 01/13/2022 02:29:16 PM

Document Has Been Signed on 01/13/2022 02:29 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ISABELLA'S HOMEFACILITY NUMBER:
486803775
ADMINISTRATOR:CRUZ-ASTORGA, SELENEFACILITY TYPE:
737
ADDRESS:915 GOLD COAST CTTELEPHONE:
(707) 759-3784
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
01/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Selene Astroga-Cruz, Licensee/AdministratorTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced at Isabella's Home and met with Selene Astroga-Cruz, Licensee & Administrator. The purpose of this case management inspection is to follow up on an incident which was self reported to Community Care Licensing (CCL) on 1/13/2022.
The following was reported: On 1/13/2022 at approximately 7:30 AM Client (C1) was found unresponsive. Staff (S1) performed CPR and 911 was immediately contacted. Emergency services arrived at approximately 7:45 AM; C1 was pronounced dead at approximately 8:00 AM. C1's responsible party, North Bay Regional Center Service Coordinator, and CCL were notified of the incident.

During today's inspection LPA conducted interviews and obtained copies of documents for Client (C1).

Exit interview was conducted with Licensee/Administrator Selene Astroga-Cruz whose signature below confirms receipt of report.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2022
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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