216801923-10-11-2021-21-AS-CFGS-C7PMNE-20211011094524

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801923
Report Date: 10/08/2021
Date Signed: 10/11/2021 09:45:40 AM

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:	YOUNG AT HEART RCFE		FACILITY NUMBER:	216801923
ADMINISTRATOR:	ROMUALDOFORTEZ,BELLANACHOR		FACILITY TYPE:	740
ADDRESS:	37 MENDOCINO LANE		TELEPHONE:	(415) 209-6185
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	6	CENSUS: 4	DATE:	10/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Romualdo Fortez - Administrator		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by administrator Romualdo Fortez & staff Shyrill Fortez. There are 4 residents present at the facility with no residents under hospice care. Facility has an activities according with residents' interests during the day. During facility tour on 10/8/2021 with administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 04/2021 at the time of the visit. Sample test of smoke & carbon monoxide detectors were found to be operational during the 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 shed outside backyard. Dangerous items were stored inaccessible to clients.Hot water temperature measured between 113.1 degrees F and 114.0 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathroom faucets. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings. Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at entrance, and facility has a designated entrance for visitors. Staff and visitors have their temperature checked and logged as well as residents. Facility has PPE supply stored in hallway closet. There has been no new staff hired with new resident’s admission. Residents’ medications are stored and locked cabinet in the kitchen by refrigerator. Facility has a 30-day supply of medication for residents. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Residents have available virtual, and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and still working towards acquiring N-95 fit testing.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: YOUNG AT HEART RCFE	FACILITY NUMBER: 216801923
	VISIT DATE: 10/08/2021

NARRATIVE

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Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file for staff at this time according with PIN 21-32 & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19). In addition, LPA had a discussion with administrator regarding visitation guidelines per PIN 21-40-ASC: UPDATED STATEWIDE VISITATION WAIVER, AND TESTING AND VACCINATION VERIFICATION GUIDANCE FOR VISITORS RELATED TO CORONAVIRUS DISEASE 2019 (COVID-19).

LPA reviewed Licensing Information System (LIS) with Licensee/Administrator who stated that is corrected and updated at this time. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted quarterly with the last one on 9/13/2021.

There were no deficiencies cited at this time.

Department is requesting the following documentation to be submitted by 10/15/2021:

LIC 308 Designation of Facility Responsibility
Copy of Liability Insurance
Copy of Administrator Certificate
Copy of Transportation Procedures

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC809 (FAS) - (06/04)

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