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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804260
Report Date: 10/03/2024
Date Signed: 10/03/2024 11:46:44 AM

Document Has Been Signed on 10/03/2024 11:46 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:CARE HOME AT RED PHEASANT, THEFACILITY NUMBER:
486804260
ADMINISTRATOR/
DIRECTOR:		HALLER, VICTORIAFACILITY TYPE:
740
ADDRESS:219 RED PHEASANT DRTELEPHONE:
(707) 430-1608
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 5DATE:
10/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Lucille Calimpon, House Manager/Administrator-in-TrainingTIME VISIT/
INSPECTION COMPLETED:
11:46 AM
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived for the purpose of conducting a Pre Licensing Inspection. LPA was met at the front door by care staff and was granted access into the facility. Fire Clearance approved for 6 nonambulatory, 1 of which may be bedridden (in Bedroom #4 only). Victoria Haller, Administrator was out of town. LIcensee was available by phone. Lucille (Chiqui) Calimpon (LC), House Manager/Administrator -in-Training and 2 additional care staff were on site at the time of inspection. There were 5 residents in care.

LPA and LC toured the one story facility, which has 5 bedrooms, 2.5 bathrooms, and large family room and kitchen. LPA observed the facility to be clean and at a comfortable temperature of 74 degrees F with all exits free from obstruction. LPA found the 2 carbon monoxide detectors and 8 smoke detectors to be operational during the inspection. The fire extinguisher was last charged on April 16, 2024 and was fully charged and operational. First Aid kit was inspected and found to be complete. Water temperature was within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen and freezer in the garage. Knives and other hazardous items were locked and inaccessible to residents in care. Medications are locked in hall closet and inaccessible to residents in care. Cleaning products and other toxins are located in the locked laundry room and inaccessible to residents in care. There was a supply of linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents were supplied with paper towels and hand soap, and outfitted with grab bars and non-slip floors/mats. A tour of all resident bedrooms was conducted, and bedrooms inspected have lighting and appropriate furnishing.

(Report continued on LIC 809C)
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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 RED PHEASANT, THE
FACILITY NUMBER: 486804260
VISIT DATE: 10/03/2024
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Continued from 809........

A review of Resident and Personnel files found them to be complete.

LPA discussed the Emergency Disaster Plan and Infection Control Plan in detail. Licensee has a supply of water, non-perishables, flashlights and PPE.

Component III was reviewed with the LC (waiting on Certificate). Licensee has been through Component III multiple times.

LPA found no deficiencies at the facility at the time of inspection.

Exit interview was conducted, and a copy of this report was given to the Licensee. LPA will forward this report to the Licensing Program Manager and assigned Application Analyst in our Department.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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