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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804033
Report Date: 01/24/2025
Date Signed: 01/24/2025 03:16:02 PM

Document Has Been Signed on 01/24/2025 03:16 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SAKURA HOMEFACILITY NUMBER:
486804033
ADMINISTRATOR/
DIRECTOR:
JENNA BALUYOTFACILITY TYPE:
735
ADDRESS:2124 TILDEN PLACETELEPHONE:
(707) 759-4553
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Jenna Baluyot, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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At approximately 9:45 AM, Licensing Program Analysts (LPAs) Julie Florio and Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and were greeted by staff. Jenna Baluyot, Administrator was contacted and arrived at approximately 10:15 AM. Facility is an Adult Residential Facility (ARF) with four clients in care. Three clients were present during today's inspection and one (1) was away at an appointment. Facility has a Hospice waiver for two (2) and currently has one client receiving Hospice care. Facility is vendorized with North Bay Regional Center (NBRC).

At approximately 10:30 AM, LPAs initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. LPAs observed the CCLD reporting poster and personal rights poster hanging in a back hallway of the facility. LPAs advised Administrator to move these posters to a more prominent, common area of the facility where the clients and their guests can view them and to post the facility's visiting hours as well to bring the facility back into compliance with regulation. Administrator agreed. Water temperatures in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of clean linens and hygiene, paper, and incontinent care products available for clients. Clients' bedrooms were inspected and 3 of 4 rooms were observed missing at least one (1) or more of the required furnishings as outlined in Title 22 regulations. Facility has care plans for these clients which reflect behavioral reasons for the removal of items from their bedrooms as well as an exception for two of the clients. LPA will consult with LPM and follow up with Administrator. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a deck and outdoor space for activities in the backyard. Facility has games and crafting supplies available for clients and has their day program send activities to the home for client who is unable to attend and requires constant 2-to-1 supervision. Facility has internet access available to clients in care, and the phone was tested an operational during today's inspection.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAKURA HOME
FACILITY NUMBER: 486804033
VISIT DATE: 01/24/2025
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Continued from LIC809...

Facility's fire extinguishers were observed charged and were last serviced 1/2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts monthly disaster drills, and the most recent drill was conducted 1/2025. LPAs observed facility's infection control plan and emergency disaster plan which was last updated 1/2025. LPAs observed a supply of PPE, emergency supplies, a first aid kit, flashlights, and two (2) backup generators for emergency preparedness.

At approximately 11:45 AM, LPAs reviewed four (4) staff files and four (4) client files. Four (4) of four (4) staff files reviewed have all the required paperwork and proof of current First Aid and CPR training. Four (4) of four (4) client files reviewed have all the required paperwork. Facility coordinates medical and dental visits for the clients and takes them to and from their appointments.

At approximately 1:00 PM, LPAs reviewed medications and medication records which are maintained and stored in compliance with regulation. LPAs reviewed P&I monies and logs, which were organized and maintained and stored in accordance with regulation. However, LPAs observed facility carrying more cash than stated on their LIC400 Affidavit Regarding Client Cash Resources and more than they are bonded to carry. Administrator immediately obtained an additional Surety bond to bring the facility into compliance with regulation.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC500 - Personnel Report (updated)
LIC400 - Affidavit Regarding Client Cash Resources

No deficiencies cited during today's inspection.

Exit interview conducted with Administrator, whose signature on form confirms receipt.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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