<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803865
Report Date: 04/29/2024
Date Signed: 04/29/2024 01:34:58 PM

Document Has Been Signed on 04/29/2024 01:34 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/
DIRECTOR:		ABILLAR, VAL HENRYFACILITY TYPE:
737
ADDRESS:7952 CHARLOTTE LANETELEPHONE:
(707) 392-4258
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 3DATE:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Val Henry AbillarTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Stefanie Mutialu and Jill Nakagawa arrived unannounced for the purpose of conducting a Required -1 Year inspection and met with Val Henry Abillar, Administrator. There are currently 3 residents in care.

LPAs 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, the last being 4/16/24 4/24/24, and 4/26/24 (one for each shift). 3 of 3 fire extinguishers were charged and serviced on 07/26/2023.. There are 6 combination hardwired smoke & carbon monoxide detectors, which were tested & observed operational. LPAs 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. Administrator's Certificate is valid until 01/17/2025.

LPAs requested the following updated forms to be submitted to Community Care Licensing by 05/15/2024:

Continued on 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: LUCIA'S HOME
FACILITY NUMBER: 486803865
VISIT DATE: 04/29/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 809.....

· LIC 500 Personnel Report
· LIC 9020 Facility Register of Client/Residents
Bacterial Water Analysis

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2