<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804079
Report Date: 11/28/2022
Date Signed: 11/28/2022 03:51:27 PM

Document Has Been Signed on 11/28/2022 03:51 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:LAGUNITA'S HOMEFACILITY NUMBER:
486804079
ADMINISTRATOR:RAQUINIO, ROMARFACILITY TYPE:
735
ADDRESS:3249 LAGUNITA CIRCLETELEPHONE:
(650) 787-2337
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
11/28/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Applicants Selene Cruz -Astroga and Romar RaquinoTIME COMPLETED:
04:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Karina Canela conducted a pre-licensing inspection on 11/28/2022. LPA met with Applicants Selene Cruz -Astroga and Romar Raquino who will be the Administrator when the facility is approved for licensure. The facility has a fire clearance approval from the Fairfield Fire Department for 1 non-ambulatory (bedroom #1) and 3 ambulatory residents (bedrooms #2-4) for a total capacity 4. Facility will operate with 24/7 staff and Licensee will ensure sufficient staffing at all times.

During today’s visit LPA observed the following items:
· Lockable separate cabinets/closets for medications, toxins, and knives.
· All exits were unobstructed
· 6 hardwired combination smoke and carbon monoxide detectors, which were tested and observed to be operational
· First Aid kit, night-lights in hallways leading to bathrooms, and flashlights for emergency lighting
· Supply of linens, paper products, and hygiene supplies available
· Grab bars and non-slip shower flooring in 2 of 2 bathrooms.
· Fire Extinguisher charged
· Required furnishings in all 4 resident bedrooms
· A shed in the backyard used for storage
· Activity supplies available
· Administrator Certifications; Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Client personal rights and visitor policy).

Pre-licensing is complete and this facility has no deficiencies.

The Component III Orientation was completed during today's visit. LPA will submit the pre-licensing application report to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
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 1