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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804125
Report Date: 06/27/2023
Date Signed: 06/27/2023 03:08:23 PM


Document Has Been Signed on 06/27/2023 03:08 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:LA CASITA SENIOR CAREFACILITY NUMBER:
576804125
ADMINISTRATOR:HERNANDEZ, JESSICAFACILITY TYPE:
740
ADDRESS:900 DUNCAN CIRTELEPHONE:
(530) 665-6277
CITY:WOODLANDSTATE: CAZIP CODE:
95776
CAPACITY:6CENSUS: 2DATE:
06/27/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Mayra and Jessica HernandezTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Post-Licensing Inspection. There are currently 2 residents at the facility. There were 2 staff on duty at the time of inspection.

The facility was clean and well-organized, and a comfortable temperature. All signage was up and in a highly visible location. Facility is waiting on poster from Ombudsmans' Office. One resident was resting outside in the shade, supervised. The other resident was resting in room with a friend visiting.

The kitchen was well-stocked with perishable and non-perishable food items, as specified in Title 22. Opened containers were labeled and dated. The facility was a comfortable temperature. Residents were clean and dressed appropriately. The fire extinguisher was accessible and fully charged. Carbon monoxide alarm was tested and operational. Facility is equipped with fire sprinklers and smoke detectors throughout. Medications were locked and inaccessible to residents and unauthorized persons. Bathrooms were clean and equipped with hand grips and non-slip mats.

Inspection of 2 out of 2 resident files showed that Admissions Agreements and Physician's Reports were up to date. 2 out of 2 staff files showed that staff are up to date on training and have first aid and CPR.

No deficiencies were found at the time of inspection. No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
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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