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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804079
Report Date: 12/26/2024
Date Signed: 12/26/2024 12:28:20 PM

Document Has Been Signed on 12/26/2024 12:28 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:LAGUNITA'S HOMEFACILITY NUMBER:
486804079
ADMINISTRATOR/
DIRECTOR:		RAQUINIO, ROMARFACILITY TYPE:
735
ADDRESS:3249 LAGUNITA CIRCLETELEPHONE:
(650) 787-2337
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
12/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Staff Member, Louie Brian Abrantes, and Licensee, Selene Cruz-AstorgaTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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At approximately 9:35am, Licensing Program Analyst (LPA) Stevenson and Licensing Program Analyst (LPA) Felias, arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Louie Brian Abrantes. Licensee, Selene Cruz-Astorga arrived at approximately 10:15AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 4 Ambulatory Clients. Upon arrival, LPAs were informed that there were 3 clients in care with one client out of the facility with family. LPAs was also informed that there was 4 staff members on-site.

At approximately 10:15am, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:55am, LPAs conducted a walk-though of the facility with Staff Member. LPAs observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 4 Client bedrooms, 2 bathrooms, and common areas. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

At approximately 10:20am, LPAs reviewed staff files, client files, client medication, and client P&I monies. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure. P&I monies were documented, secure and not commingled. Administrator's Certificate for Romar Raquinio (7033977735) was expired with a date of 12/23/2024. Review of the Department's pending list indicated that their renewal application was received as of 08/15/2024.

Fire extinguishers were last inspected October 2024. Smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted December 2024.



Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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: LAGUNITA'S HOME
FACILITY NUMBER: 486804079
VISIT DATE: 12/26/2024
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Continued from LIC809

LPAs requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Active and Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by due date of 01/26/2025.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Licensee. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC809 (FAS) - (06/04)
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