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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803869
Report Date: 06/13/2024
Date Signed: 06/13/2024 03:47:08 PM

Document Has Been Signed on 06/13/2024 03:47 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:HYDEE'S CARE HOME LLCFACILITY NUMBER:
486803869
ADMINISTRATOR/
DIRECTOR:
RAMIREZ, HYDEEFACILITY TYPE:
735
ADDRESS:1175 JACK LONDON DRIVETELEPHONE:
(707) 704-8353
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 3DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Jane Ramirez, Assistant AdminstratorTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Required 1 Year inspection at 1:50 PM. LPA was allowed entrance by Jane Ramirez, Assistant Administrator. Administrator Hydee Ramirez, was attending a training at the time.

LPA and Assistant Administrator toured the facility and found the facility to be a comfortable temperature and organized. Facility has a fire clearance for 4 ambulatory and 2 non-ambulatory clients. The facility has combined smoke alarms with carbon monoxide detector, which was inspected by Fire Department on 2/28/2024. All exits were clear and unobstructed. The hot water was within regulation of 105 - 120 degrees F. Clients' bathroom had grab bars and non-slip surfaces. There were paper towels and hand soap available. LPA observed a sufficient supply of perishable and non-perishable food as required. Sharps and medications were locked in cabinets in kitchen making them inaccessible to clients in care. The LPA observed a sufficient supply of cleaners, hygiene products, and paper products.The facility has sufficient furnishings for clients' use as well as activities for clients.

LPA will have to continue inspection at a later time.

No deficiencies cited during this visit.

Exit interview conducted with Jane Ramirez. Copy of Inspection Report left at facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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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