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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804033
Report Date: 09/12/2022
Date Signed: 09/12/2022 05:27:37 PM

Document Has Been Signed on 09/12/2022 05:27 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: 2DATE:
09/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jenna Baluyot, interim AdministratorTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced for the purpose of conducting a post-licensing inspection. LPA met with Administrator Elinore Ramas and Jenna Baluyot, Interim Administrator. LPA observed 2 clients in care.

During today’s visit LPA observed the following items:
· COVID-19 screening station, LPA was screened upon entering
· Lockable separate cabinets for medications, toxins/cleaners, and knives.
· All exits were unobstructed
· 4 smoke detectors and 2 combination smoke and carbon monoxide detectors
· 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
· Client's medication was centrally stored and locked.
· Food supplies were within regulation
· P & I funds are secured and not commingled.
· A spot check of Facility records were reviewed for Clients and staff. Staff have initial and ongoing training documented, including CPR and 1st Aid certifications.

No deficiencies cited during today's inspection
Exit interview conducted with Jenna Baluyot, Interim Administrator, whose signature below confirms receipt.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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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