216803577-9-12-2021-21-AS-CFGS-C6ST23-20210912142002

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803577
Report Date: 09/09/2021
Date Signed: 09/12/2021 02:20:09 PM

Document Has Been Signed on 09/12/2021 02:20 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:	WALDO HOUSE		FACILITY NUMBER:	216803577
ADMINISTRATOR:	WILLIE RIVIORE		FACILITY TYPE:	735
ADDRESS:	55 WALDO COURT		TELEPHONE:	(415) 271-3304
CITY:	SAUSALITO	STATE: CA	ZIP CODE:	94965
CAPACITY: 5		CENSUS: 5	DATE:	09/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Karen Lewis - Lead Staff		TIME COMPLETED:	03:30 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 Analysts (LPA) Fernandes-Goes conducted an unannounced Annual 1 yr. Required Infection Control inspection to this facility and was welcome by staff Damaris Snyder. Administrator was contacted by staff an wasn’t able to come, however; lead staff Karen Lewis arrived during the visit. Facility has 5 clients present at this time. Facility has activities for residents during the day. LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 9/9/2021 with lead staff Karen Lewis, facility was found to be at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, garage, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 5/2021 at the time of the visit. Sample testing of Smoke Detectors & Carbon monoxide detector were operational. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Facility has no residents with special dietary need at this time. Food is available for clients any time of the day. Facility takes clients on outings, and conduct activities during the day. Toxins are stored in a locked closet in the hallway. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for clients at the facility were supplied with towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of client’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Facility hot water temperature at clients' bathroom faucet measured 111.9 degrees F within Title 22 acceptable regulations of 105 to 120 degrees F. Continue LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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: WALDO HOUSE	FACILITY NUMBER: 216803577
	VISIT DATE: 09/09/2021

NARRATIVE

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Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance facility has hand sanitizer and other items designated for visitors and staff as they come into work. Facility has PPE supply stored in office closet and storage. Facility hasn’t hired staff or admitted new clients since COVID-19.

Clients’ medications are stored and locked in kitchen cabinet. Facility has a 30-day supply of medication for clients. Clients aren’t wearing masks inside the facility, however; lead staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. 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-ASC & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19) In addition, facility to follow updated guidelines for visitors according with PIN 21-40-ASC: UPDATED STATEWIDE VISITATION WAIVER, AND TESTING AND VACCINATION VERIFICATION GUIDANCE FOR VISITORS RELATED TO CORONAVIRUS DISEASE 2019 (COVID-19)

In addition, facility allowing visitors in the facility. Clients have also available telephone calls when contacting with family members and others. Staff had all PPE training required on file and are working towards getting staff N-95 fit testing.

LPAs advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted once a month with last one being conducted on 7/1/2021.

In addition, LPA gather more information regarding incident report that was submitted to the Department by the facility.
There were no deficiencies cited at this time.
Deparment is requesting the following to be submitted to CCL by (/17/21:
LIC 500, LIC 400, LIC 402, LIC 610

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

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