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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804033
Report Date: 02/01/2022
Date Signed: 02/01/2022 03:45:25 PM

Document Has Been Signed on 02/01/2022 03:45 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:SAKURA HOMEFACILITY NUMBER:
486804033
ADMINISTRATOR:RAMAS, ELINOREFACILITY TYPE:
735
ADDRESS:2124 TILDEN PLACETELEPHONE:
(916) 743-9292
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
02/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Elinore Ramas, ApplicantTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Karina Canela conducted a pre-licensing inspection on 02/01/2022.
LPA met with applicant Elinore Ramas, who will be the Administrator once the facility is approved for licensure. Additionally Paula Baluyot was present. The facility has a fire clearance approval from the Fairfield Fire Department of 1 non-ambulatory and 3 ambulatory, for a total capacity of 4 clients. Facility will operate with 24 hour staffing and Licensee will ensure sufficient staffing at all times.

During today’s visit LPA observed the following items:
· COVID-19 postings and screening station
· Lockable separate cabinets for medications, toxins/cleaners, and knives.
· All exits were unobstructed, · 3 charged Fire Extinguishers
· 4 smoke detectors and 2 combination smoke and carbon monoxide detectors, which were tested and observed operational
· Complete first Aid kit, night-lights, and flashlights for emergency lighting
· Supply of linens, paper products, and hygiene supplies available
· Grab bars in non-ambulatory bathroom
· Required furnishings in all 4 bedrooms
· Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster).
· The water temperature was tested during inspection

report continued on LIC809-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAKURA HOME
FACILITY NUMBER: 486804033
VISIT DATE: 02/01/2022
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The Component III Orientation was completed.

Pre-licensing is incomplete with corrections needed.

The following items are needed to proceed with the application process:

- Non-skid mat in 1 of 2 bathrooms

- Receipt of purchase for 3 fire extinguishers which were observed without a tag

- Proof of Active Administrator's Certification

- Posting of the facility's theft and loss procedures

Applicant to submit pictures to LPA as proof of correction. Once LPA receives pictures of correction, LPA will submit the pre-licensing application report to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

No deficiencies cited

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
LIC809 (FAS) - (06/04)
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