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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804052
Report Date: 06/06/2024
Date Signed: 06/06/2024 04:11:09 PM

Document Has Been Signed on 06/06/2024 04:11 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:C & R CARE HOME LLCFACILITY NUMBER:
486804052
ADMINISTRATOR/
DIRECTOR:
BAYOT, ROBERT CHRISTIANFACILITY TYPE:
740
ADDRESS:373 HERON WAYTELEPHONE:
(510) 789-5155
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 5CENSUS: 5DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator/Licensee, robert BayotTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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At approximately 1:40 PM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced annual required inspection of this licensed senior care facility. LPA was greeted by Sallome Magon,caregiver. Administrator, Robert Bayot arrived shortly after. The facility is a single story home licensed for six (5) non-ambulatory residents and a hospice waiver capacity of five. The facility currently provides care for five residents. In addition, there are two residents on hospice.

At approximately 1:55 PM, LPA and Administrator toured the building and grounds which was found to be clean and in good repair. All notices that are required to be posted have been posted. LPA advised Administrator CCL Annual Report (last 12 months) must be posted in highly visible area. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked cabinet in the hallway. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in a lock box in a kitchen cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Water temperature measured within regulation between 114 and 115 degrees F at three of three faucets accessible to residents. One out of one fire extinguisher was inspected and charged. Six out of Six Combo Smoke/Carbon Monoxide detectors were present, inspected and found in working order. There was enough lighting in all common areas, resident rooms, and hallways.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: C & R CARE HOME LLC
FACILITY NUMBER: 486804052
VISIT DATE: 06/06/2024
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Medications located in designated cabinet were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Five of five residents were found in their room. Residents were observed resting in their rooms napping or watching television. LPA observed staff checking on residents and preparing food.

At approximately 2:45 PM, LPA reviewed Five of five resident records which were all found to be well organized, thorough and contained the required documentation. At approximately 3:10 PM , LPA reviewed two out of two staff records which were all found to be well organized, thorough and contained the required documentation.


Administrator Robert Bayot's Administrator Certification 7026826740 is current and expires on 11/05/2025.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC 500 Personnel Summary
LIC 9020 Register of Facility Client’s/Resident's
LIC308 Designation of Facility Responsibility
Liability Insurance


No citations issued during today’s visit.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
LIC809 (FAS) - (06/04)
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