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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800414
Report Date: 12/03/2021
Date Signed: 12/03/2021 12:26:13 PM

Document Has Been Signed on 12/03/2021 12:26 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CAREMAX, INC. - DELGANADO HOUSEFACILITY NUMBER:
216800414
ADMINISTRATOR:DIZON, AGNESFACILITY TYPE:
735
ADDRESS:786 DELGANADO ROADTELEPHONE:
4155070955
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 4DATE:
12/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Administrator, Agnes DizonTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Caremax, Inc.-Deganado House for the purpose of conducting a Required-1 year inspection. LPA was met at the door by, Administrator, Agnes Dizon and was granted access into the facility.

LPA toured the facility and found the facility was clean and well organized. All exits unobstructed. Hot water tested at 108 F degrees. Smoke; Fire; Carbon Monoxide, all current. Clients in day programs at the time of the visit. Facility was a comfortable temperature. Bedrooms and bathrooms were clean and appropriately furnished. Grounds free of any hazards. Fresh and non-perishable food in adequate supply. Medication and toxins locked and stored away. No bodies of water. No firearms. Disaster drill log current. The amount of fresh and non-perishable foods was within regulation. Toxins are secure and not accessible to clients. There is a sufficient supply of hygiene products and linens on hand for client use. Fire extinguishers inspected were charged dated 11/2021. First Aid kit was appropriate at the time of the inspection. Smoke detectors were tested and found to be in working order. Carbon Monoxide detector was present. All client’s bedrooms have lighting & appropriate furnishings, and client’s beds were outfitted with mattress pads as required by Title 22 Regulations # 85088(c)(4).

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has on site supply of PPE and off site supply of PPE. Staff are in the process of obtaining N95 Fit testing. Staff have had all PPE training required.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the Licensee, Willie Yang.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2021
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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