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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601533
Report Date: 05/26/2022
Date Signed: 05/27/2022 08:15:10 AM


Document Has Been Signed on 05/27/2022 08:15 AM - 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CAMELLIA GARDEN IIFACILITY NUMBER:
075601533
ADMINISTRATOR:SAVIDGE, ROSITAFACILITY TYPE:
740
ADDRESS:390 EL DIVISADERO AVENUETELEPHONE:
(925) 457-5942
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:ROSITA SAVIDGETIME COMPLETED:
03:15 PM
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On 05/26/22 at 10:15AM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with S1, S2, and S3 upon entry. Administrator Rosita Savidge arrived shortly thereafter and toured facility with LPA inside and out.

Facility has a COVID-19 mitigation plan in place dated 03/01/21 that they are following. The designated infection control leader is the administrator. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch temperature probe. COVID-19 signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants.

All staff and clients have been fully vaccinated. The LPA and Administrator discussed the infection control plan from the PIN 22-13-ASC that will need to be created for the 06/30/22 due date. A written Emergency/Disaster plan was posted on the bulletin board for staff, clients and visitors to read. Centrally stored medications were in locked cabinets. The temperature inside of the facility was 75.2 degrees and the hot water was 110 degrees, both of which were within the safe range. Sharp objects and toxic chemicals were stored in a locked closets and cabinets.

Continued on next page LIC 809-C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CAMELLIA GARDEN II
FACILITY NUMBER: 075601533
VISIT DATE: 05/26/2022
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Resident interview was very positive concerning the quality of care they had received over the one year they had lived at the facility. Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fire extinguisher was fully charged and purchased in January 2022. The Smoke and Carbon monoxide detectors were operational.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 06/02/22:

· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· LIC610E - Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

No deficiencies cited during this visit.

Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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