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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803925
Report Date: 09/24/2024
Date Signed: 09/24/2024 12:22:02 PM


Document Has Been Signed on 09/24/2024 12:22 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:AMEERA CAREFACILITY NUMBER:
486803925
ADMINISTRATOR:ELSA MAGAOAYFACILITY TYPE:
740
ADDRESS:2568 BOXWOOD LANETELEPHONE:
(925) 818-6415
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 6DATE:
09/24/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elsa Magaoay, AdministratorTIME COMPLETED:
12:30 PM
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At approximately 9:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management -- annual continuation inspection and was greeted by Elsa Magaoay, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care, two of whom are currently receiving Hospice care. LPA requested all resident files and medications for review.

At approximately, 9:50 AM, LPA conducted file review of all six (6) resident files and observed the following: six (6) of six (6) resident files reviewed contained all the required documents per Title 22 regulations. LPA observed the two Hospice residents' Hospice care plans.

At approximately 11:30 AM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation.

No deficiencies cited during today's inspection. Exit interview conducted with Administrator whose signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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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