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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801961
Report Date: 01/27/2023
Date Signed: 01/27/2023 02:51:32 PM

Document Has Been Signed on 01/27/2023 02:51 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. - QUIETWOOD HOMEFACILITY NUMBER:
216801961
ADMINISTRATOR:YANG, WEI & LI,JUANFACILITY TYPE:
735
ADDRESS:490 QUIETWOOD DRIVETELEPHONE:
(415) 225-6868
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 4CENSUS: 4DATE:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Staff Member, Jocelyn Farreau, and Administrator Willie YangTIME COMPLETED:
03:00 PM
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At approximately 12:15PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required - 1 Year visit, and met with Staff Member, Jocelyn Farreau. Administrator, Willie Yang, arrived later during visit at approximately 12:30PM. The inspection is focused on the Infection Control procedures and practices of this facility.

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. 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 daily. 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 staffing, N-95 fit-testing, activities, PPE, and training. Facility has a plan in place if a staffing shortage were to occur. Facility has submitted their Mitigation/Infection Control Plan to Community Care Licensing (CCL).

Fire extinguishers were last serviced November 2022. The last facility fire and evacuation drill was conducted in January 2023. Smoke Detectors and Carbon Monoxide alarms were tested and operational.

Continued on LIC-809C.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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: CAREMAX, INC. - QUIETWOOD HOME
FACILITY NUMBER: 216801961
VISIT DATE: 01/27/2023
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Continued from LIC-809

LPA requested the following documents to update facility file:

Facility Documents
  • Affidavit regarding Client/Resident Cash Resources (LIC 400)
  • Updated Facility Sketch (LIC 999)
  • Lease
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Current Administrator Certificate
  • Surety Bond (LIC 402)
  • Liability Insurance
  • Register of Clients/Residents (LIC 9020)

Facility Documents to be submitted to CCL by due date of Monday, February 6th, 2023.

No Deficiencies Cited during visit.

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: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC809 (FAS) - (06/04)
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