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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804125
Report Date: 01/17/2024
Date Signed: 01/17/2024 03:15:10 PM


Document Has Been Signed on 01/17/2024 03:15 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: 3DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Jessica Hernandez, AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Required 1-Year Annual Inspection on 01/17/2024. LPA met with Jessica Hernandez, who is the Licensee/Administrator. There was one additional caregiver and 3 clients in residency at the time of inspection.

Facility was found to be clean and exits were unobstructed. There are 2 bathrooms that were clean, sanitary and appropriately furnished with non-slip mats, shower chairs, soap and paper towels. The kitchen was clean and well-organized. There was an ample supply of perishable and non-perishable food as required as per Title 22. Sharps were kept in a locked drawer in the kitchen. Soaps and cleaning supplies were stored in a locked cupboard under the kitchen sink. The living room provided a nice seating area with a large television and lounge chairs for residents to elevate their legs. Bedrooms were furnished as per regulation with additional homey touches. There were plenty of extra linens. The office area includes a locked cabinet for medications and resident records. There is also a covered patio in the back yard which provide seating and a ramp for residents' easy access. Smoke detectors and carbon monoxide detectors and fire doors were tested and operational. Facility's last fire drill was held on 1/3/24. The fire extinguisher was fully charged. There was a sufficient amount of cleaning supplies and hygiene products available. LPA observed adequate emergency food and water supply. Toxins secured in the garage, which is locked and alarmed.

LPA will return at a later date to review records.

No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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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