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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486890050
Report Date: 05/09/2023
Date Signed: 05/09/2023 03:13:53 PM

Document Has Been Signed on 05/09/2023 03:13 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:NATIONAL VALLEJOFACILITY NUMBER:
486890050
ADMINISTRATOR:MARRAMA, DEBRAFACILITY TYPE:
772
ADDRESS:3467 EDGEWATER PLACETELEPHONE:
(408) 688-4737
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Debra MarramaTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with Debra Marrama, Administrator. This facility is licensed for up to 6 ambulatory clients and provides short term crisis residential treatment program. There is currently five(5) clients in care.

LPA toured facility and grounds with Program Manager, Jose Mata and observed the home be clean, organized and at a comfortable temperature with all exits free from obstruction. Clients rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 113 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinet in garage containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in the garage. Facility has smoke detectors located throughout the facility as well as a Carbon Monoxide detector that were operational during inspection. Most recent disaster drill was conducted 4/3/2023. Fire Extinguishers were found to be last charged and serviced on July 22,2023.

Two staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Debra Marrama #6058928735 expired 4/18/2023 but is on the Department's Pending List. Medications and medication records were reviewed.


Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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: NATIONAL VALLEJO
FACILITY NUMBER: 486890050
VISIT DATE: 05/09/2023
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Continued from LIC809

Licensee and LPA discussed the Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit copies of the following documents by 6/9/2023:



LIC 500 Personnel Summary
LIC 308 Designation of Responsibility
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)
Copy of lease agreement



Exit interview conducted with Debra Marrama
No deficiencies cited during today's inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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