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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801807
Report Date: 08/01/2023
Date Signed: 08/01/2023 03:02:37 PM

Document Has Been Signed on 08/01/2023 03:02 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:YERBA BUENA RESIDENTIAL CARE HOMEFACILITY NUMBER:
496801807
ADMINISTRATOR:MARTINEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:5200 YERBA BUENATELEPHONE:
(707) 539-6780
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 6DATE:
08/01/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Caregiver, Noel Marayag
Licensee, Angelica Martinez		TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Yerba Buena Residential Care Home for the purpose of conducting a Case Management-Annual Continuation Inspection. LPA was greeted at the door by Caregiver, Noel Marayag and was granted access into the facility. Licensee arrived 15 minutes later.

During the Case Management-Annual Continuation, LPA reviewed 2 of 2 staff files and found those files to be appropriate during the Required 1 year inspection. LPA reviewed 6 of 6 resident records. However, LPA observed 1 out of 6 residents did not have a physician signature on an LIC 602 (See LIC 9102-Technical Advisory). 6 of 6 Medication Orders were reviewed with the Licensee. LPA interviewed 2 of 2 staff members. LPA interviewed 4 of 6 residents. Remainder of residents were asleep during the inspection. LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308-Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Liability insurance
Control of Property
Resident Roster

No deficiencies were observed or cited during today's Case Management-Annual Continuation Inspection. Exit interview was conducted and a copy of this report was given to the facility Caregiver.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
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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