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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803865
Report Date: 05/08/2025
Date Signed: 05/08/2025 01:26:55 PM

Document Has Been Signed on 05/08/2025 01:26 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: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: 4DATE:
05/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Kristel Acosta-Lead Staff TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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At approximately 10:00AM, Licensing Program Analyst (LPA) Contreras conducted an unannounced Annual Required inspection to this facility and met with lead staff and designee of responsibility, Kristel Acosta.

LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and expiration dates. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. Toxins are secure and not accessible to clients.

There is a sufficient supply of hygiene products and linens on hand for client use. Mattress pads were in place or available for Client use. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. Fire extinguishers inspected 5/07/2024 were charged. Smoke detectors were tested and found to be in working order. Private vendor comes to facility to inspect alarms. Carbon Monoxide detector was present. Last disaster drill was conducted 2/25/2025

LPA conducted inspection of facility van and car. Both cars were equipped with fire extinguisher but was missing first aid kit in facility van. LPA had discussion to ensure that van is equipped with first aid kit at all times. Administrator agreed to ensure there is a kit inside van and placed a first aid kit during inspection.

Continued on 809-C.....

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LUCIA'S HOME
FACILITY NUMBER: 486803865
VISIT DATE: 05/08/2025
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Continued from 809...

Facility has an outdoor area with a sun room accessible to clients at all times. Outdoor is used for gardening and feeding chickens. Sun room is equipped with chairs and table for outdoor activities.

LPA reviewed 4 of 4 Client records and 4 staff records, which were all found to be well organized, thorough and contained the required documentation. First aid and CPR certification were current in 4 out of 4 staff files reviewed.

Medication is centrally stored and secure for all clients. Medication was in locked cabinet and inaccessible to clients. Centrally Stored Medication log had some typo errors. Prescription number not updated from last medication cycle to current medications. LPA advised admin to ensure prescription number is always up to date and put in correctly with updated date.

P&I monies were documented, secure and not commingled.

Updated copies of the following documents to be sent to CCL within 30 days of visit:
LIC500- Personnel Report
LIC308- Designation of Responsibility
Updated Surety Bond

No deficiencies were observed in the areas inspected. No citations issued during today’s visit.

Exit interview conducted.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/08/2025 01:26 PM - It Cannot Be Edited


Created By: Ethel Contreras On 05/08/2025 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LUCIA'S HOME
FACILITY NUMBER: 486803865

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025


LIC809 (FAS) - (06/04)
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