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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803041
Report Date: 02/16/2023
Date Signed: 02/16/2023 02:25:57 PM


Document Has Been Signed on 02/16/2023 02:25 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 HOMA GUEST HOME, LLCFACILITY NUMBER:
286803041
ADMINISTRATOR:DASTGHEIB, ALIFACILITY TYPE:
740
ADDRESS:1161 LA HOMA DRIVETELEPHONE:
(707) 252-7426
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 6DATE:
02/16/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lead Staff, Raymond GoTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 02/16/2023 to conduct a Legal/Non-Compliance inspection. LPA met with lead staff, Raymond Go. Facility had COVID postings at the front entrance and COVID questionnaires available to screen visitors and staff.

LPA toured building and grounds which were clean and in good repair. Exits and walkways were clear from obstructions. Facility currently has 6 residents, one is on hospice. Facility has approved hospice exception for resident. Medications are centrally stored and secured. Residents were observed participating in activities in the living room. Facility also had activity schedule posted. Toxins are locked and inaccessible. LPA observed sufficient perishable and non-perishable food as well as a menu posted. Fire extinguishers were charged and current. Carbon monoxide and smoke detectors were present and operational. Bathrooms had necessary grab bars and non-slip mats. Facility staff were observed wearing masks. All staff and residents are fully vaccinated and boosted. LPA and lead staff reviewed Central Medication/Destruction record. Lead staff, Raymond Go has passed the examination to be a certified administrator. LPA provided lead staff with certificate number.

Report emailed to administrator.

Exit interview conducted with lead staff, Raymond Go.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
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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