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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804238
Report Date: 07/29/2024
Date Signed: 07/29/2024 12:16:55 PM

Document Has Been Signed on 07/29/2024 12:16 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:CARE HOME AT LARAMIE, THEFACILITY NUMBER:
486804238
ADMINISTRATOR/
DIRECTOR:		ADRIANO, RONMARKFACILITY TYPE:
740
ADDRESS:512 LARAMIE WAYTELEPHONE:
(707) 592-3539
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 4DATE:
07/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:47 AM
MET WITH:Ron-Mark Adriano, Administrator
and Robert Coleman, via phone		TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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On 7/29/2024 Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced visit for the purpose of completing a pre-licensing evaluation. This pre-licensing inspection is being conducted due to a change of ownership. LPA was greeted by caregiver. Administrator Ron-Mark Adriano arrived shortly and conducted a tour of the facility. The facility is a 5 bedroom 3 bathroom single story house. There are currently 4 residents in care some of which are diagnosed with Dementia. There were 3 staff on site at the time of inspection.

LPA toured the entire premises which were found to be clean, orderly and a comfortable temperature. Three fire extinguishers were last inspected on 09/26/2023 and fully charged. Eight smoke detectors tested and found to be in working order. Carbon monoxide detector was located in the main hallway and found to be in working order. Medications, facility files, emergency supplies and sharps are stored in a locked closet in entryway. Toxins and cleaning supplies are secured in a locked laundry room leading to the garage. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for 4 clients. Beds were made with appropriate linens. Furniture appeared safe and adequate. Hot water temperature was measured and within regulation between 105 degrees F and 120 degrees F. There was an ample supply of dishes and cooking supplies.

Required postings such as Complaint poster, Rights to resident councils, client's rights are posted in the facility. Resident and staff records, all contained required documentation and secured in the medication closet.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: CARE HOME AT LARAMIE, THE
FACILITY NUMBER: 486804238
VISIT DATE: 07/29/2024
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A fire clearance for this facility has been granted for 6 non-ambulatory clients and a hospice waiver for 3.

Component III orientation was conducted with the Administrator.

The pre-licensing evaluation has been completed. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations. License will be granted upon completion of a final review and approval from the Licensing Program Manager.

This report will be forwarded to the Centralized Application Unit for continued processing.

This report was reviewed with Administrator applicant and a copy was provided.

No deficiencies were cited during today's visit.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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