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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803781
Report Date: 01/30/2024
Date Signed: 01/31/2024 12:54:32 PM


Document Has Been Signed on 01/31/2024 12:54 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:ADELAIDE HOME IIFACILITY NUMBER:
486803781
ADMINISTRATOR:MONTECLAR, IRENEFACILITY TYPE:
740
ADDRESS:1155 MAHOGANY CTTELEPHONE:
(707) 207-3941
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:4CENSUS: 3DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jasmine Aliscad, Administrator-in-TrainingTIME COMPLETED:
03:30 PM
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On 01/30/2024 at 12:45 PM Licensing Program Analyst (LPA) Jill Nakagawa arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator-in-Training Jasmine Aliscad (JA).

LPA and JA toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, two (2) bathrooms, common areas, kitchen, storage areas, garage and yard. The facility was found to be well-maintained, clean, sanitary and well-organized. Bedrooms of residents are decorated to highlight their interests, and had required furnishings. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food was found to be stored properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. The common area was clean and decorated for Valentine's Day and had plenty of space for activities, meals, and socialization.


Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet. Facility also utilizes a medication cart and a treatment cart, which are locked.

The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Two (2) fire extinguishers were fully charged and serviced on 10/6/2023. Smoke detectors and fire alarm system passed inspection on 10/6/2023. Carbon monoxide detectors tested and found to be operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. ( Continued on 809-C)
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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: ADELAIDE HOME II
FACILITY NUMBER: 486803781
VISIT DATE: 01/30/2024
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Continued from 809

All employees requiring background checks are cleared. All required postings are displayed within facility. No pools/bodies of water are on the premises. No firearms are on premises.

The last disaster drill was conducted and documented on 12/22/2023; the facility has been conducting drills every month.

No deficiencies found at the time of inspection. No citations issued.



Exit interview conducted with Administrator-in-Training and copy of report was provided to administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
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