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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804132
Report Date: 05/05/2023
Date Signed: 05/05/2023 02:03:00 PM

Document Has Been Signed on 05/05/2023 02:03 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:IMAGINE AT UNIONFACILITY NUMBER:
486804132
ADMINISTRATOR:PUNZALAN, VIRGINAFACILITY TYPE:
735
ADDRESS:830 UNION AVETELEPHONE:
(818) 642-3943
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
05/05/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Virginia Punzalan, ApplicantTIME COMPLETED:
02:14 PM
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Licensing Program Analyst (LPA) Karina Canela conducted a pre-licensing inspection on 05/05/2023 at Imagine at Union. LPA met with applicant Virginia Punzalan, who will be the Administrator once the facility is approved for licensure. Patricia and Jerome Bucal were also present. The facility has a fire clearance approval from the city of Fairfield Fire Department for a total of 4 ambulatory only residents. The facility does not have approval to accept or retain non-ambulatory or bedridden residents. Facility will operate with 24 hour staffing and Licensee will ensure sufficient staffing at all times.

During today’s visit LPA observed the following items:
· COVID-19 screening station at entrance
· Lockable separate cabinets for medication, toxins, and knives.
· All exits were unobstructed
· 7 smoke detectors and 1 carbon monoxide detector were tested and observed operational
· First Aid kit, night-light, and flashlights for emergency lighting
· Supply of linens, paper products, and hygiene supplies available
· Fire Extinguisher charged and serviced 01/11/2023
· Required furnishings in 4 of 4 bedrooms
· Administrator Certification; Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Client personal rights and visitor policy).
· The water temperature was tested during inspection and was within regulation of 105-120 Degrees F.

Pre-licensing is complete and this facility has no corrections needed.
The Component III Orientation was completed. 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: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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