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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108000
Report Date: 02/24/2023
Date Signed: 02/24/2023 09:31:47 AM


Document Has Been Signed on 02/24/2023 09:31 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:MC HUGH CARE HOMEFACILITY NUMBER:
490108000
ADMINISTRATOR:DIZON, TIFFANYFACILITY TYPE:
740
ADDRESS:1000 GORDON LANETELEPHONE:
(707) 545-8213
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:15CENSUS: DATE:
02/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Caregiver, Myla RublicoTIME COMPLETED:
09:41 AM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Caregiver, Myla Rublico. Manager, Charito Santos was available by phone.

LPA is following up regarding resident, R1 who recently passed away but was not on hospice. LPA reviewed documents and spoke with caregiver who provided a timeline of events. Manager has agreed to provide LPA a copy of the death certificate once it is available.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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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