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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201000
Report Date: 11/08/2021
Date Signed: 11/09/2021 09:22:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:ELEGANCE AT DUBLINFACILITY NUMBER:
019201000
ADMINISTRATOR:WHITTEMORE, WESLEYFACILITY TYPE:
740
ADDRESS:7601 AMADOR VALLEY BLVDTELEPHONE:
(360) 975-4709
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:80CENSUS: 30DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Jennifer Coons, AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection at approximately 12:30 PM, and met with Administrator, Jennifer Coons. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA toured facility and grounds with Administrator and observed some COVID-19 precaution signs posted in common areas to promote hand washing and physical distancing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Staff follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test within 72 hours. Staff clean and disinfect the facility daily. Administrator stated high touched surface areas are disinfected daily and victory spray is used. There is hand sanitizer throughout the facility. Bathrooms are equipped with liquid soap, paper towels and garbage cans with touch less lids. Staff understand hand sanitizer should not be placed in the rooms of residents who lack hazard awareness and impulse control. Facility submitted a Covid-19 mitigation plan, and plan was reviewed 8/2/2021. Caregivers have completed PPE training and some have been N-95 Fit tested.
This facility is licensed to serve up to 80 residents. There are 4 floors being used and facility consists of living room/front area, activity rooms, gym, theater room, indoor outdoor dining and 80 private resident room. No accessible bodies of water or fire safety hazards observed. Fire Extinguisher were found to be charged and serviced 9/10/2021. Floors have stair evacuation chairs. Facility has hard wire Smoke alarms, fire sprinklers that are serviced yearly and Carbon monoxide detectors.
LPA requested a Copy of Change of Administrator paperwork.
Exit interview conducted with Administrator. Due to printer malfunction, this report will be emailed to Administrator.
No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) -58-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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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