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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803718
Report Date: 03/29/2024
Date Signed: 03/29/2024 01:32:08 PM

Document Has Been Signed on 03/29/2024 01:32 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:EDRINE HOMEFACILITY NUMBER:
486803718
ADMINISTRATOR:BALAURO, NESTORFACILITY TYPE:
735
ADDRESS:503 VIA VAQUEROTELEPHONE:
(650) 703-1217
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 4DATE:
03/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Nestor Balauro, AdministratorTIME COMPLETED:
01:45 PM
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On 3/29/2024, Licensing Program Analysts (LPA's) Tobola & Matialu conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Administrator, Nestor Balauro. Licensee, Kevin Braud and Manager, Irene Monteclar arrived later in the visit. The facility currently provides care for 4 clients, 2 of which were attending day program at the time of visit. LPA continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 7/26/2023. Smoke and carbon monoxide detectors were interconnected found throughout the facility, tested and to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. Water at faucets accessible to clients was measured at 111.0 degrees F which is within Title 22 Regulations.

Facility conducts and records emergency disaster drills on a quarterly basis. Medications are located in a designated medication cart and found to be secured. A spot medication count was conducted for client and found to be in order along with properly documented centrally stored medication records. LPA conducted a review for staff files and found all staff to have 1st Aid & CPR certification and annual training on file. Staff's (S1) Health Screening Report was requested by LPA's. Technical Assistance issued. S1 is newly hired and the facility is in the process of completing S1's documentation requirements. In addition, LPA's reviewed client record and found majority of documents including Needs & Service Plan, North Bay Regional Center Individual Program Plans and Physician's Reports to be current. LPA's requested for a copy of client (C1) Physician's Report as it was not located on file. C1 has not had any major changes of condition since admission. Technical Violation issued. Clients attending day program are currently provided transport to and from the facility from both the facility or directly from the day programs. There is a sufficient supply of linens, hygiene product and paper products available for client use.

LPA's observed several documented items in clients' (C1, C2 & C3) files in need of signatures. Information had been input and facility agrees to acquire proper documented signatures to ensure compliance. Technical Assistance issued.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2024
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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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: EDRINE HOME
FACILITY NUMBER: 486803718
VISIT DATE: 03/29/2024
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Facility vehicle was inspected and found to be equipped with proper emergency items. Current Administrator, Nestor Balauro's Administrator Certification has expired as of February 2024 and currently in the process of renewing their certification. Administrator has submitted training requirements to CCLD.

LPA's requested for documentation and copies of the training hours by POC date 4/11/2024.
Administrator, Irene Monteclar's Administrator Certification 6017547740 is current through 6/23/2024.

LPA requested the following documents be sent to CCL by COB 4/29/2024:

LIC 610 Emergency Disaster Plan
Proof of ownership/Control of Property

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC809 (FAS) - (06/04)
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