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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801077
Report Date: 02/10/2022
Date Signed: 02/10/2022 12:00:51 PM

Document Has Been Signed on 02/10/2022 12:00 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:CAREMAX, INC. - PEACH STONE HOMEFACILITY NUMBER:
216801077
ADMINISTRATOR:AGNES DIZONFACILITY TYPE:
735
ADDRESS:440 PEACH STONE TERRACETELEPHONE:
(415) 479-6580
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 4DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Licensee, Willie YangTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived Unannounced at Caremax, Inc.-Peach Stone Home for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Licensee, Willie Yang.

LPA toured the facility with Licensee Willie Yang on February 10, 2022. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 11/2021 at the time of the inspection. First aid kit was inspected and found to be appropriate at the time of the inspection. Facility smoke detectors and carbon monoxide were inspected and are properly operating. Hot water temperature measured between 105 degrees F and 120 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in client’s bathroom while touring facility. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored inaccessible to clients. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels and hand soap. 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 PPE supply located at the entrance. Staff have had all PPE training and have had N95 Fit testing.

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 Mr. Yang.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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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