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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803829
Report Date: 07/17/2023
Date Signed: 07/18/2023 05:07:12 PM


Document Has Been Signed on 07/18/2023 05:07 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:LOCUST GUEST HOMEFACILITY NUMBER:
486803829
ADMINISTRATOR:JULIUS RAMIREZFACILITY TYPE:
740
ADDRESS:223 LOCUST DRTELEPHONE:
(707) 980-6366
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 33DATE:
07/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Julius RamirezTIME COMPLETED:
04:42 PM
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Licensing Program Analyst (LPA), Araceli Canela arrived at Locus Guest Home unannounced for the purpose of conducting a Required-1 year inspection. LPA met with care staff Belinda and Lorido "Larry" Morete. Administrator, Julius Ramirez was called and arrived a few minutes later.

This facility is licensed for 6 non-ambulatory residents, no approval for Hospice services or bed ridden. LPA toured the home and found the home to be at a comfortable temperature with all exits free from obstruction. The home was found clean and organized. There are a total of five bedrooms in the home and all bedrooms are approved to be used by residents. There is no room available for staff and facility understands and has awake staff. Smoke detectors and carbon monoxide detectors were tested and operational. The fire extinguisher located in the laundry room was observed charged and serviced June 8, 2023. Fire drill was conducted by the facility and documented on 4/5/2023. There are auditory alerts on exit doors which were tested and functional. Water temperature in the resident bathrooms were tested and found to be within appropriate range of 105-120 degrees. Bathrooms have required non-skid surfaces and grab bars. Cleaning products and knives are stored in a locked cabinets in the kitchen. There is adequate space and furniture on the patio for outdoor activities. Fire place is observed with a screen.

There was a 7 day supply of non-perishable foods. There are adequate dishes, glasses and silverware. There is a locked cabinet that stores residents' medications. Resident and staff files are located and locked in the Credenza.
LPA reviewed staff files and staff have the required training and proof of CPR/1st aid that expires 5/13/2024. Resident files were reviewed and LPA consulted regarding Admission Agreements and updating "refund" policy per regulations.

Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
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: LOCUST GUEST HOME
FACILITY NUMBER: 486803829
VISIT DATE: 07/17/2023
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Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit the current following documents by 8/17/2023:


· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Liability Insurance- LPA verified it is current until 5/21/2024 and copy was provided during visit.



No citations issued during todays inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC809 (FAS) - (06/04)
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