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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803337
Report Date: 05/07/2024
Date Signed: 05/07/2024 04:19:37 PM


Document Has Been Signed on 05/07/2024 04:19 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:BUCKINGHAM RESIDENTIAL CARE HOMEFACILITY NUMBER:
496803337
ADMINISTRATOR:MARTINEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:954 BUCKINGHAM DRIVETELEPHONE:
(707) 888-5259
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:6CENSUS: 5DATE:
05/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Staff Member, Erwin Marayag, and Licensee/Administrator, Angelica MartinezTIME COMPLETED:
04:25 PM
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At approximately 3:40PM, Licensing Program Analyst (LPA) Felias, arrived unannounced to conduct a Case Management - Other Visit and met with Staff Member, Erwin Marayag. Licensee/Administrator, Angelica Martinez, arrived during visit at approximately 4:00PM. The purpose of the visit is to confirm an Order to Individual for Immediate Exclusion for All Facilities.

The Department delivered an "immediate exclusion" notice on 04/29/2024 to facility. Per notice, Staff Member 1 (S1) cannot be allowed to work, be present and/or live in a CCL licensed facility, or have contact with residents in any residential facility or child day care licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with residents and not allow this employee to be physically present in the facility.

Licensee/Administrator informed LPA that S1 had been removed from the facility and from the facility's staff roster. Licensee/Administrator stated they understood the notice.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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