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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803935
Report Date: 10/03/2024
Date Signed: 10/03/2024 02:32:04 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/03/2024 02:32 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:L & A RESIDENTIAL CARE HOMEFACILITY NUMBER:
486803935
ADMINISTRATOR/
DIRECTOR:
BAUTISTA, ROMULO N JRFACILITY TYPE:
740
ADDRESS:455 JERRYLEE ROADTELEPHONE:
(510) 750-2003
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 6DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Romulo Bautista, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Inspection. The Residential Care Facility has 6 residents. The facility has a waiver for 6 hospice. There were 2 staff on site.

LPA was allowed access by carestaff. Administrator arrived shortly.


LPA conducted a walk-through of the facility with Administrator. Required postings were observed at the entrance to building. Facility was a comfortable temperature. Fire Extinguisher was fully charged and last serviced on 08/15/2024 and easily accessible. All smoke detectors and carbon monoxide detectors are hardwired and operational, and checked monthly. Last fire drill was done on 10/01/2024. Water temperature was within regulation in 2 out of 2 bathroom faucets tested. All exits were unobstructed and doors were operational, with auditory alarms on all external doors. There was an ample supply of fresh and non-perishable foods. Linens were in good supply. Residents were supplied with activities and a nice area to socialize and visit, with a lovely little garden full of squash and tomatoes.

LPA performed a review of staff and resident files and found them to be complete. Staff are current on the CPR and First Aid training, as well as initial and yearly trainings.

Exit interview conducted with Romulo Bautista, Administrator whose signature on this document confirms receipt.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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