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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803967
Report Date: 06/20/2023
Date Signed: 06/20/2023 01:24:08 PM

Document Has Been Signed on 06/20/2023 01:24 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:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Harlyne Sally, House ManagerTIME COMPLETED:
01:23 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Required 1-year annual inspection and was greeted by Staff, Harlyne Sally. The Licensee, Marie Fernandez arrived later. At the time of inspection there were 3 staff providing care and supervision for 1 client.

The facility is posting the screening questions for Covid-19 at the front door and screening and logging visitors at the time of entry.

The facility was a comfortable temperature of 70 F and was clean and well-organized. The clients' bedrooms had the required furnishings, plus many items to make each resident's space personal and appealing to them. Staff cleaning schedules are posted in the hallway. The facility common areas are cleaned and wiped down often. Bathrooms were stocked with hand washing supplies. The water temperature measured 117 F, within the required 105-120 F. The facility had 1 fire extinguisher which was last serviced on 6/2/22 and was fully charged. Fire Extinguisher Company was scheduled to come and service again on 6/23/23. The fire alarm/smoke detector system was tested and functional. The 4 carbon monoxide detectors were tested and functioning.

LPA reviewed 3 staff and 3 client records. LPA discussed documentation of staff trainings.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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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