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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800343
Report Date: 08/22/2022
Date Signed: 08/22/2022 12:03:50 PM

Document Has Been Signed on 08/22/2022 12:03 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:BAY HOME INCFACILITY NUMBER:
216800343
ADMINISTRATOR:KAREN BIRDFACILITY TYPE:
735
ADDRESS:19 HEARTHSTONE CTTELEPHONE:
(415) 507-0235
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:House Manager, Tak Horiuchi TIME COMPLETED:
12:15 PM
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At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with House Manager, Tak Horiuchi. The visit is focused on the Infection and Control Practices of this facility. Administrator, Karen Bird, was not available for today's visit but was available via telephone.

Upon arrival at the facility, LPA had their temperature checked and logged. LPA answered a standard COVID-symptom questionnaire. LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

Facility has a cleaning and disinfecting schedule that occurs at least once per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for clients. Staff and Clients are screened daily for COVID-19 symptoms and it is logged into facility binders.

LPA and Administrator discussed N-95 Fit testing, activities, and PPE. Facility has a plan in place if a staffing shortage were to occur.

Fire extinguishers were last serviced July 2022. Facility has a central pull fire alarm system that is directly connected to the Fire Department. Carbon Monoxide detectors were tested and operational.

Continued on LIC-809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BAY HOME INC
FACILITY NUMBER: 216800343
VISIT DATE: 08/22/2022
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Continued from LIC-809

LPA requested the following documents to update facility file:
  • Administrative Organization (LIC 309)
  • Affidavit Regarding Client/Resident Cash Resources (LIC 400)
  • Articles of Incorporation or Organization
  • Emergency Disaster Plan (LIC 610D)
  • Personnel Report (LIC 500)
  • Surety Bond (LIC 402)
  • Register of Clients (LIC 9020)
  • Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by Friday, September 30, 2022

No Deficiencies cited during this inspection.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC809 (FAS) - (06/04)
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