<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804014
Report Date: 12/29/2021
Date Signed: 12/30/2021 09:43:12 AM

Document Has Been Signed on 12/30/2021 09:43 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ZAMORA FAMILY HOMEFACILITY NUMBER:
486804014
ADMINISTRATOR:POWELL, JENNIFERFACILITY TYPE:
735
ADDRESS:116 SUNSET AVE.TELEPHONE:
(510) 828-1019
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 3CENSUS: 0DATE:
12/29/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ernesto ZamoraTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Araceli Canela conducted a pre-licensing inspection on 12/29/2021. LPA met with Applicant Ernesto Zamora and toured the inside and outside of the home. The facility received a fire clearance approval from the Vallejo Fire Department on 10/25/2021 for a total capacity of 3 ambulatory clients. Facility will operate from the top level of the home with a live-in staff; Licensee will ensure sufficient staffing at all times.

During today’s visit LPA observed the following items:
  • COVID-19 postings and screening station at entrance
  • Lockable separate cabinets for medications, toxins, and knives
  • All exits were unobstructed
  • 4 smoke detectors & 1 carbon monoxide detector
  • First Aid kit, night-lights, and flashlights for emergency lighting
  • Supply of linens, paper products, and hygiene supplies available
  • Fire Extinguisher charged and will be serviced yearly
  • Required furnishings in both 2 client bedrooms
  • Administrator Certification for Jennifer Powell (EXP: 10/21/2022)
  • Required postings (Personal Rights, Emergency plan/numbers, Visitors Policy, CCL complaint)
  • Facility has submitted their Mitigation Plan (LIC808)


The Component III Orientation was completed during today's visit with applicant, Ernesto Zamora.

Pre-Licensing is complete and this facility has no deficiencies, LPA will submit the pre-licensing application report to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1