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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804149
Report Date: 06/27/2024
Date Signed: 06/27/2024 04:45:05 PM

Document Has Been Signed on 06/27/2024 04:45 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:SAKURA HOME 2FACILITY NUMBER:
486804149
ADMINISTRATOR/
DIRECTOR:
BALUYOT, JENNA NICHOLEFACILITY TYPE:
735
ADDRESS:2024 SWAN WAYTELEPHONE:
(916) 743-9292
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
06/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Jenna Baluyot, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 6/27/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Administrator, Jenna Baluyot. The facility currently provides care for 3 clients, all of which were present 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 Extinguishers were found to be last charged on 6/17/2024. Smoke and carbon monoxide detectors found throughout the facility, tested and 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 with appropriate coverings. Water at faucets accessible to clients were measured at 110.2 degrees F which is within regulation. Facility conducts and records emergency disaster drills on a monthly basis, with appropriate emergency exit signs and evacuation maps posted. LPA observed missing window screen located in client restroom. Administrator to submit photo corrections. Technical Violation issued.

There is a sufficient supply of linens, hygiene product and paper products available for client use. Items that could pose danger to client if accessible were found to be secured. There are two storage areas, one located in the back of the facility and an additional shed located in the backyard, both of which showed no signs of inhabitants. Clients were observed to have a positive relationship with staff and found participating in personal activities and appointments during the visit.

Medications and facility records are stored in the garage, all of which were found to be secured. Upon a spot check, medications and administration records were all found to be in order. LPA conducted a review for 3 out of 3 staff files and found all staff to have 1st Aid & CPR certification and annual training on file. Upon review of 3 out of 3 client files, LPA found that clients' (C1 & C2) physician's reports indicate that they are not able to handle their own cash resources. However, upon interview with Administrator, LPA was informed that C1 & C2 utilize personal debit cards. LPA requested for Administrator to contact client Service Coordinator and Primary Physician's to update client physician's reports for consistency. Technical Violation Issued. Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAKURA HOME 2
FACILITY NUMBER: 486804149
VISIT DATE: 06/27/2024
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Lastly, LPA Tobola conducted a follow up after facility self reported client (C1) previously demonstrating aggressive behaviors towards client (C2) and towards facility staff. LPA found that the facility has implemented sound proof padding in client's (C2) bedroom to prevent altercations from occurring. In addition, the facility is ensuring sufficient 1:1 staffing ratio's for all clients and redirection for both client C1 & C2, preventing least amount of interaction with one another. No additional incidents have occurred within the past several weeks. LPA found that the facility has responded appropriately to incidents.

LPA requested the following documents be sent to CCL by COB 7/27/2024:

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 the visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
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