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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804033
Report Date: 02/23/2023
Date Signed: 02/23/2023 11:51:41 AM

Document Has Been Signed on 02/23/2023 11:51 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, 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: 3DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jenna Baluyot, Future Administrator and Elinore and Dennis Ramas, Licensee/AdministratTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Inspection on 02/23/2023. This inspection is focused on Covid-19 protocols and practices. At the time of inspection there was one resident in the facility who is currently on Hospice. 2 other residents were out at their respective Day Programs. There were two staff.

LPA met with Jenna Baluyot, who is in the process of becoming the Administrator: paperwork to be submitted shortly. The facility is working with Fire Department for bedridden clearance and was installing a new fire door, as per their request. New Facility Sketch and Fire Dept. Notice will be forwarded to CCL directly.

The facility has a paved back yard, with deck and ramp for access to the back bedroom. There is a locked shed for storage as well as a small locked building for staff quarters.

At the time of inspection the house was clean, well-organized and a comfortable temperature. Each resident's room was outfitted according to their special needs and interests. There were plenty of extra linens and towels. The kitchen had adequate perishable and non-perishable food supplies. Sharps were stored in a small drawer, locked and inaccessible. There was a small, locked medication refrigerator on the kitchen counter. Other medications were stored and locked in the office. The facility has two bathrooms, one outfitted for residents, with a large shower area (complete with grab bars and non-skid mat) and the other for staff. There were two fire extinguishers, serviced and fully charged on January 6, 2023. There were two operational smoke/CO2 alarms.

There were no deficiencies found at the time of inspection. No citations issued.


SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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