486804079-10-13-2023-21-AS-DTOA-CWKPJ2-20231013112048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804079
Report Date: 10/13/2023
Date Signed: 10/13/2023 11:20:53 AM

Document Has Been Signed on 10/13/2023 11:20 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:	LAGUNITA'S HOME		FACILITY NUMBER:	486804079
ADMINISTRATOR:	RAQUINIO, ROMAR		FACILITY TYPE:	735
ADDRESS:	3249 LAGUNITA CIRCLE		TELEPHONE:	(650) 787-2337
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 4		CENSUS: 0	DATE:	10/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Selene Cruz-Astroga, Licensee		TIME COMPLETED:	11:30 AM

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	On 10/13/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Licensee, Selene Cruz-Astroga. The facility currently provides care for 2 clients, both of which were attending day program or on outings at the time of visit. LPA continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher purchased within the last year. The Licensee will be contacting fire inspection agency to conduct fire extinguisher inspection and submit photo proof of charge once completed. Smoke and carbon monoxide detectors were found throughout the facility, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. Water at faucets accessible to clients was measured at 109.2 degrees F which is within Title 22 Regulations. Client bedrooms were well maintained and had appropriate bedding and furnishings. Facility conducts and records emergency disaster drills on a quarterly basis with emergency exits signs and evacuation plans clearly posted. Medications are located in a designated closet located in the hallway and found to be secured. A spot medication count was conducted for clients and found to be in order along with properly documented centrally stored medication records. LPA conducted a review for staff files and found all staff to have 1st Aid & CPR certification and annual training on file. In addition, LPA reviewed all client records and found all documents including Needs & Service Plan, North Bay Regional Center Individual Program Plans and Physician's Reports to be current. One out of two clients are currently attending day program 5 days per week, with the second client in the process of identifying an appropriate job or day program. There is a sufficient supply of linens, hygiene product and paper products available for client use. Client P&I funds were also observed to be secured and not commingled, reviewed and found to be in order. Continued onto LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 486804079
	VISIT DATE: 10/13/2023

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There is an ample amount of indoor and outdoor space available for client use with a variety of activities and supplies based on their preferred interests. A storage shed located in the backyard was found to be secured and contained no items that could be a risk to clients if accessible. Emergency exit located in the side yard was also found to be unobstructed. Clients are encouraged to participate in community outings and develop independent skills with staff support. All clients participate in grocery shopping and work with staff on creating healthy food options. The facility is currently providing adequate staff to client care ratios and provides appropriate engagement for the benefit of client improved behaviors.

Administrator, Romar Raquinio's Administrator Certification 6022314735 is active and valid until 12/23/2024

LPA requested the following documents be sent to CCL by COB 11/13/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Proof of ownership/Control of Property

No deficiencies cited during today's visit.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

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