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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803865
Report Date: 05/30/2023
Date Signed: 05/30/2023 04:17:49 PM

Document Has Been Signed on 05/30/2023 04:17 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:LUCIA'S HOMEFACILITY NUMBER:
486803865
ADMINISTRATOR:ABILLAR, VAL HENRYFACILITY TYPE:
737
ADDRESS:7952 CHARLOTTE LANETELEPHONE:
(707) 392-4258
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
05/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:Val Henry Abillar, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Karina Canela arrived for the purpose of conducting a Required -1 Year inspection and met with Val Henry Abillar, Administrator.
LPA toured the facility, all exits were unobstructed. The facility was found to be clean & at a comfortable temperature. LPA observed a supply of arts/crafts, linens (bedding, towels, etc.), and cleaning solutions (observed locked & inaccessible). Liquid hand soap and paper towels are available in bathrooms. 4 of 4 client bedrooms were fully furnished per regulation. Facility food supply was within regulation and accessible to clients. Medication was centrally stored. Water temperature was tested and observed between 105 to 120 degrees F.
Disaster Drills are conducted quarterly as required. 3 of 3 fire extinguishers were charged and serviced 10/18/2022. There are 6 combination hardwired smoke & carbon monoxide detectors, which were tested & observed operational. LPA reviewed staff and client records. Staff have current training certifications in First Aid & Cardiopulmonary Resuscitation (CPR) in file. Client files are complete and up-to-date. Client P&I funds are not commingled.

LPA requested the following updated forms to be submitted to Community Care Licensing by 06/30/2023:
· 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 9020 Facility Register of Client/Residents
· LIC 610D Emergency Disaster Plan
· Copy of current Administrator's Certificate

Exit interview conducted with Administrator, 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: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2023
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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