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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486890073
Report Date: 08/23/2024
Date Signed: 08/23/2024 04:40:16 PM

Document Has Been Signed on 08/23/2024 04:40 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:SHIR-LEE'S CARE HOMEFACILITY NUMBER:
486890073
ADMINISTRATOR/
DIRECTOR:
LOFTON, ANGELAFACILITY TYPE:
735
ADDRESS:2548 TENNESSEE STREETTELEPHONE:
(707) 648-2964
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 4CENSUS: 2DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:19 PM
MET WITH:Hope Lofton, Care staffTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with Hope Lofton, Care staff. Angela Lofton, Licensee/Administrator was available by phone. There are currently 2 clients in care.

LPA toured facility and grounds with care staff and observed the home to be at a comfortable temperature with all exits free from obstruction. Client rooms were furnished per regulation. Water temperature accessible to clients in care measured within the required regulation range of 105 to 120 degrees F. Extra hygiene products and linens were available. Cleaning supplies are locked and not accessible to clients. 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. Facility has emergency packs available in the office. Medications were centrally stored and locked in medication file closet along with client files.

Fire extinguishers are charged and were last serviced 6/27/2024. Smoke/Carbon Monoxide detectors are operational. Most recent fire/disaster drill was conducted August 15, 2024.

Client files were reviewed and in compliance. Staff have required First Aid and CPR certificates that expire 7/3/2025. Administrator, Angela Lofton's Administrator certificate expires July 22, 2025.

LPA requested the following updated records to be submitted to Community Care Licensing by 9/22/2024

· LIC 500 Personnel Report
· LIC 9020 Register of Facility Clients
Exit interview conducted with Hope Lofton, No deficiencies cited during today's inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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