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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804125
Report Date: 03/28/2023
Date Signed: 04/21/2023 03:28:50 PM


Document Has Been Signed on 04/21/2023 03:28 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/19/2023 03:43 PM

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

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Licensing Program Analyst (LPA) Jill Nakagawa conducted an announced pre-licensing inspection on 03/28/2023. LPA met with Jessica Hernandez, who is the Licensee/Administrator and Mayra Hernandez, Licensee/Caregiver, once the facility is approved for licensure.

The facility has a fire clearance approval from the City of Woodland Fire Department for a total capacity of 6 Clients: 4 ambulatory and 2 non-ambulatory (the facility does not have approval for bedridden). The 2 non-ambulatory clients are restricted to bedroom 5. Facility will operate with 24/7 staffing and Licensee will ensure sufficient staffing at all times. The facility is a one-story home, with 5 bedrooms, 2 bathrooms, a kitchen, living room, sitting room and dining room. There is also a covered patio in the back yard with provided seating and a ramp for residents' easy access.

Smoke and carbon monoxide detectors were tested and appeared to be operational. The fire extinguisher was purchased on 01/15/2023. The applicant has designated at least two emergency disaster locations.

First aid kit had all components required per regulation. Emergency lighting was available. Bedrooms were furnished with chairs, dressers, beds with padding and appropriate lighting. Bathrooms had hand washing supplies and paper products. There was a sufficient amount of cleaning supplies and hygiene products available. LPA observed adequate emergency food and water supply. Toxins will be secured in the garage, which is locked and alarmed. Medication will be locked in a closet and inaccessible to clients in care.

Continued on 809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LA CASITA SENIOR CARE
FACILITY NUMBER: 576804125
VISIT DATE: 03/28/2023
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LPA conducted a COMP III with applicants. The following items were discussed: Reporting Requirements, Clients behaviors and Personal RIghts, Personal Accommodations, Criminal Background clearance, Acceptance and Retention, Guardian, Restricted and Prohibited Health Care Conditions.

This pre-licensing is complete. LPA will submit the pre-licensing reports to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicants of application status. A copy of the report was given to the Applicants.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC809 (FAS) - (06/04)
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