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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803967
Report Date: 04/29/2022
Date Signed: 04/29/2022 04:20:00 PM

Document Has Been Signed on 04/29/2022 04:20 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:LONGSPUR MANORFACILITY NUMBER:
486803967
ADMINISTRATOR:FERNANDEZ, ASHLEYFACILITY TYPE:
735
ADDRESS:1107 LONGSPUR DRTELEPHONE:
(415) 939-4491
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 4DATE:
04/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Frances Fernandez, AdministratorTIME COMPLETED:
04:30 PM
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At approximately 2:00 PM, Licensing Program Analysts (LPA's) Walters arrived unannounced to conduct a Case Management - Incident Visit and met with Licensee, Frances Fernandez (FF).

LPA and FF discussed a self-reported incident occurring on 4/22/22 involving C1 which resulted in an self-injurious that caused resident to be admitted into the hospital. LPA reviewed C1's Physician report, made observations and interviewed staff. Client has returned to the facility and is receiving follow-up care. Facility has increased supervision as a precaution and have discussed consent with clients.

No Deficiencies cited during this visit. Exit interview conducted with FF, A copy of the report was given.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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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