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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803935
Report Date: 11/03/2020
Date Signed: 11/03/2020 01:00:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:L & A RESIDENTIAL CARE HOMEFACILITY NUMBER:
486803935
ADMINISTRATOR:BAUTISTA, ROMULO N JRFACILITY TYPE:
740
ADDRESS:455 JERRYLEE ROADTELEPHONE:
(510) 750-2003
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 0DATE:
11/03/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Romulo Bautista, AdministratorTIME COMPLETED:
12:58 PM
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On 11/3/2020 Licensing Program Analyst (LPA) Dominic Tobola conducted a video tele-visit for the purpose of completing a pre-licensing evaluation. This pre-licensing inspection is being conducted for an initial licensure. The video tele-visit must be conducted due to COVID-19 restrictions. LPA was greeted by Administrator Applicant Romulo Bautista and conducted a tour of the facility. The facility is a 5 bedroom 4 bathroom single story house with no residents in care. LPA toured the entire premise which was found to be clean and orderly.

Fire extinguisher last inspected 9/27/2020 was mounted and charged. Smoke detectors throughout the facility were tested and found to be in working order. Carbon monoxide detectors are connected to each smoke detector and found to be in working order. Medications, facility files and emergency supplies are kept in a locked medication cabinet in the dinning room. Sharps are stored in a locked food pantry in the kitchen. Toxins and cleaning supplies are secured in a locked cabinet in the laundry room.

LPA observed at least a minimum of a 7 day supply of non-perishable food necessary for 6 clients. Administrator plans to purchase a minimum of a 3 day supply of perishable foods once the facility plans to admit their first resident. The kitchen is stocked with an ample amount of silverware, cooking supplies and dishes.

Beds were made with appropriate linens. There is a closet located in the resident hallway that holds extra linens and towels. Furniture is appeared safe and adequate. Hot water temperature was measured between 108 and 110 degrees F and within regulation between 105 degrees F and 120 degrees F.

Report continued on LIC809-C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: L & A RESIDENTIAL CARE HOME
FACILITY NUMBER: 486803935
VISIT DATE: 11/03/2020
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Required postings such as Complaint poster, Rights to resident councils, client's rights are posted on the facility bulletin. Resident and staff records, have all been prepared with required forms and secured in the medication cabinet.

A fire clearance for this facility has been granted for 0 bedridden and 6 non-ambulatory clients. Two emergency exits along each side of the facility are unobstructed and equipped with self closing latches.

Administrator Applicant Romulo Bautista's Administrator Certificate 6055097740 expires 2/3/2022.
Component III orientation was conducted with the Licensee and Administrator Applicant.

The pre-licensing evaluation has been completed. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations. License will be granted upon completion of a final review and approval from the Licensing Program Manager.

This report will be forwarded to the Centralized Application Unit for continued processing.

This report was reviewed with applicant and a copy was provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
LIC809 (FAS) - (06/04)
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