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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803775
Report Date: 08/29/2023
Date Signed: 08/29/2023 05:50:11 PM

Document Has Been Signed on 08/29/2023 05:50 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:ISABELLA'S HOMEFACILITY NUMBER:
486803775
ADMINISTRATOR:ANGELICA B. GONZALODOFACILITY TYPE:
737
ADDRESS:915 GOLD COAST CTTELEPHONE:
(707) 759-3784
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Angelica Gonzalodo, Administrator/RBTTIME COMPLETED:
06:30 PM
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Licensing Program Analysts (LPA) Carol Fowler made an unannounced Required- 1 year inspection of this licensed facility and met with Administrator Angelica Gonzalodo, Administrator Selene Cruz Astorga arrived shortly after.

LPA toured the building and grounds which were found to be clean and in good repair. All walkways and exits were observed unobstructed. Water temperature was tested and within regulation between 105 and 120 degrees F. The fire extinguisher was charged and serviced 01/16/2023. Smoke detectors and carbon monoxide combo were tested and found to be in working order during inspection. Facility is equipped with fire sprinklers. Medications were centrally stored and locked in the dining room cabinet. Facility has at least two days of perishable and one week of non-perishable foods, food was stored properly.

LPAs reviewed 4 resident records and 5 staff records which were all found to be thorough and well organized and contained the required documentation. Medication was reviewed. First aid/CPR certification was current. Administrator Certificate for Selene Cruz-Astorga, #6019085735, expires on 08/10/2024 and Administrator Certificate for Angelica B Gonzalodo #6036738735, expires 2/20/2024. Last Fire drill was conducted and documented on 7/17/2023.

Licensee/Administrator to send in updates of the following documents by 09/05/2023:
Designation of Administrative Responsibility (LIC308)
Personnel Report (LIC500)
Emergency Disaster Plan (LIC610E)
Register of clients LIC9020
Administrators Certificate.
Control of Property

No citations issued during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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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