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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803935
Report Date: 09/01/2023
Date Signed: 09/01/2023 12:40:41 PM


Document Has Been Signed on 09/01/2023 12:40 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:BAUTISTA, ROMULO N JRFACILITY TYPE:
740
ADDRESS:455 JERRYLEE ROADTELEPHONE:
(510) 750-2003
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 6DATE:
09/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Romulo Bautista, Licensee/AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Inspection and met with Romulo Bautista, Administrator. The Residential Care Facility currently has 6 residents. There were 2 staff on site.

LPA observed a screening station at the entrance of facility which had hand sanitizer, a thermometer, and a sign-in station for visitors. Masks are available.


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 8/19/23 and easily accessible. All Fire Alarms are hardwired and operational. 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., both inside and outside.

LPA observed a supply of PPE. Staff are current on the CPR and First Aid training. The facility has submitted an Infection Control Plan.

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

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
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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