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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830786
Report Date: 01/28/2025
Date Signed: 01/28/2025 03:46:05 PM

Document Has Been Signed on 01/28/2025 03:46 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OUR LADY OF PEACE HOME CAREFACILITY NUMBER:
486830786
ADMINISTRATOR/
DIRECTOR:
CABE, ROMEOFACILITY TYPE:
740
ADDRESS:900 DAWNVIEW WAYTELEPHONE:
(707) 447-1920
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Romeo Cabe, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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01/28/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 6 residents in care. There are currently 3 residents on hospice. Facility approved/cleared for 6 non-ambulatory, and hospice waiver for 5. LPA met with Administrator, Romeo Cabe.

LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

LPA observed board games accessible for residents. Facility has a weekly food menu on display. Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Water temperature in sinks accessible to residents in care were measured at 118.1 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 08/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Sharps were found to be secured in a locked drawer located in the kitchen. There was a supply of hygiene products and paper products available for residents. Toxins are in a locked cabinet located in the laundry room. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Facility conducts fire and emergency disaster drills monthly with the last one being conducted 12/31/2024. Facility has oxygen signs posted at each door for residents who are using oxygen. Facility has staff quarters and is located in the backyard.

LPA conducted a review of 4 resident records. All records had the required documentation. LPA conducted review of 3 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.



No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/28/2025:

continued on LIC809-C
Kimberley MotaTELEPHONE: (707) 588-5071
Anthony LoeraTELEPHONE: (707) 588-5026
DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OUR LADY OF PEACE HOME CARE
FACILITY NUMBER: 486830786
VISIT DATE: 01/28/2025
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LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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