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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804149
Report Date: 06/09/2023
Date Signed: 06/09/2023 11:58:27 AM

Document Has Been Signed on 06/09/2023 11:58 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:SAKURA HOME 2FACILITY NUMBER:
486804149
ADMINISTRATOR:BALUYOT, JENNA NICHOLEFACILITY TYPE:
735
ADDRESS:2024 SWAN WAYTELEPHONE:
(916) 743-9292
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
06/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jenna Baluyot, Licensee Applicant TIME COMPLETED:
12:15 PM
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On 6/9/2023, Licensing Program Analyst's (LPA) Tobola arrived announced to conduct a pre-licensing inspection and was greeted by Licensee Applicant, Dennis Ramas and Administrator, Jenna Baluyot. This pre-licensing inspection is being conducted as an initial facility application. Fire Clearance has been approved for 4 ambulatory and 1 non-ambulatory residents. There are currently 0 residents in care. The facility is a 5 bedroom 2 bathroom single story home.

LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Multiple fire extinguishers are located throughout the facility found to be charged on 6/6/2023. Smoke detectors and carbon monoxide detectors were present and all functional. Hot water measured between 110.6 & 111.9 degrees in faucets used by residents which falls within regulation between 105 & 120 degrees F. There was an ample supply of linens, dishes and cooking supplies. There was a sufficient supply of cleaning supplies and hygiene products available for residents. Facility is in the process of vendorization under North Bay Regional Center and prior to admission; facility will acquire appropriate food supply. Facility was found to be a comfortable temperature with all facility building and outdoor exits free from obstruction. Toxins and cleaning supplies were observed to be secured located in the garage. In addition, all knives and other sharp items were found to be in a designated locked drawer in the kitchen. LPA found facility hallways in need of floor/night-lights. Facility has purchased and will install. Photos to be sent to CCLD.

Medications will be centrally stored in cabinets located in a secured garage along with medication records. A second refrigerator is located in the garage for clients that may require refrigerated medication. Facility has prepared blank templates of all appropriate Licensing forms for incoming resident and staff records, all contained in a secured location. Required postings such as Rights to resident councils, client's rights and Complaint Poster are posted at the client common areas and visible to staff and clients.

LPA observed staff living/rest quarters located on the facility side yard. Facility sketch does not indicate staff living quarters however Licensee Applicant stated Fire Inspector is aware and has inspected the room. LPA is requesting for Licensee Applicant to update facility sketch and resubmit fire clearance inspection request for final approval by Plan of Correction date 6/19/2022. Licensee Applicant is to provide CCL with updated Fire Clearance once completed.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2023
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: SAKURA HOME 2
FACILITY NUMBER: 486804149
VISIT DATE: 06/09/2023
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Licensee Applicant will be providing CCLD with the following corrections:
- Floor lights installed in hallways
- Updated fire inspection and clearance for outdoor staff rest area

Component III orientation was conducted with the Licensee Applicant.

The pre-licensing evaluation has been completed. License will be granted upon completion of fire re-inspection visit and a final review and approval from the Licensing Program Manager.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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