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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804094
Report Date: 10/27/2023
Date Signed: 10/27/2023 01:19:57 PM


Document Has Been Signed on 10/27/2023 01:19 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:VILMA'S HOMEFACILITY NUMBER:
486804094
ADMINISTRATOR:NICOLAS, JETHROFACILITY TYPE:
740
ADDRESS:2925 GULF DR.TELEPHONE:
(650) 745-5080
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:4CENSUS: 4DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Nina German, Co- Administrator, LVNTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a 1-Year Required Inspection on 10/27/2023. LPA met with Nina German, LVN and Co-Administrator., There were 3 residents on site at the time of inspection, 1 was at Day Program. There were 3 staff present at the time of inspection.

The facility was a comfortable temperature of 70 F. The facility was clean and well-organized and decorated in a homelike way, with each resident's room decorated to reflect their personality. The facility has a fire clearance approval for 4 non-ambulatory residents: total capacity 4. Facility has a waiver for 2 hospice. There were 2 Fire Extinguishers fully charged and last inspected on 12/02/2022. A fire drill was conducted on 07/26/2023. There are smoke/carbon monoxide detectors throughout the facility: all were functioning. The water temperature of bathroom faucets was 109.5 F. The kitchen was well-equipped and sharps were locked and inaccessible to residents. There was ample perishable and non-perishable food, as required by regulation.
There are to-go bags for each resident, a first aid kit and water stored for emergencies.

The grounds of the facility were free of debris and had nice walkways which allow residents to access the back patio and herb garden.

No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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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