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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108000
Report Date: 06/28/2023
Date Signed: 06/28/2023 03:25:01 PM


Document Has Been Signed on 06/28/2023 03:25 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: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: 0DATE:
06/28/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Licensee Angelita Aquino and Acting Administrator, Nicanor AquinoTIME COMPLETED:
03:30 PM
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An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager Bethany Moellers, Licensing Program Analysts Marisol Cuadra, Victoria Bertozzi and representatives of the facility, Licensee Angelita Aquino, Acting Administrator, Nicanor Aquino and Administrative Assistant, Charito Santos.

The purpose of the informal conference is to address concerns regarding Administrator Certification for this facility and the Licensee's other facility, AA Best Care 496801684 in which Nicanor Aquino is the identified Administrator.

Per discussion, Licensee has submitted training documents to the Administrator Certification Unit to renew their Administrator Certificate. Nicanor is currently working on training hours and once complete, will submit their renewal application. Licensee agrees to submit training documents along with a written plan that includes who will oversee the facilities while the certification is pending by 6/28/2023. Once plan is received, citation issued during 5/09/2023 Annual Inspection will be cleared.

LPA will follow up with the Administrator Certification Unit to determine pending status.

No deficiencies cited during today's meeting.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
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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