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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801723
Report Date: 04/14/2022
Date Signed: 04/14/2022 01:29:20 PM

Document Has Been Signed on 04/14/2022 01:29 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:BEACON HILLFACILITY NUMBER:
216801723
ADMINISTRATOR:BENOIT, WILSONFACILITY TYPE:
735
ADDRESS:826 HAYDEN AVE.TELEPHONE:
(415) 897-9716
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 6DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Wilson Benoit - AdministratorTIME COMPLETED:
01:27 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with administrator Wilson Benoit. Licensee Wally Hyppolite was present during this visit. Some clients were present at the facility. Some clients at this facility are in day program and/or working. There are activities planned for clients during the day if they want to participate.

LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 4/14/2022 with administrator Wilson Benoit facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on xxxx at the time of the visit. Carbon monoxide detector was operational during visit. Sample test of Smoke detectors was conducted and were operational during this visit. 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 in a locked cabinet inside the garage. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. Client’s bedrooms that were inspected had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Facility hot water temperature in clients' bathroom faucets measured between 110.6 degrees F and 111.3 degrees F in 2 out of 2 faucets within Title 22 acceptable regulations of 105 to 120 degrees F. Disaster Drills have been conducted every six months with the last one being conducted on 1/7/2022.

Continued LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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: BEACON HILL
FACILITY NUMBER: 216801723
VISIT DATE: 04/14/2022
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Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility; hand sanitizer designated for visitors are at entrance as well as questionnaire regarding COVID symptoms. Staff before coming into work has temperature checked. Facility has PPE supply stored in the recreation room. There has been no new staff hired and/or new clients since COVID-19. Clients’ medications are stored and locked in medication cabinet inside office room. Facility has a 30-day supply of medication for clients. Clients are sometimes wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. Staff had masks on during this visit. Clients have available virtual visits and telephone calls when contacting with family members and others. Staff stated that they have had all PPE training required on file and staff had N-95 fit testing conducted.

There were no deficiencies cited at this time.

Department is requesting Licensee to update the following documents and submit to CCL by 4/21/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrator's Certificate
Copy of Lease Agreement &/or Deed
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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