216803814-3-3-2022-21-AS-SHAN-CC6QRK-20220303112403

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803814
Report Date: 03/02/2022
Date Signed: 03/03/2022 11:24:18 AM

Document Has Been Signed on 03/03/2022 11:24 AM - 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:	SLEEPY HOLLOW VILLA		FACILITY NUMBER:	216803814
ADMINISTRATOR:	RUIZ, ERIC		FACILITY TYPE:	740
ADDRESS:	2 LEGEND RD		TELEPHONE:	(415) 460-0999
CITY:	SAN ANSELMO	STATE: CA	ZIP CODE:	94960
CAPACITY: 6		CENSUS: 0	DATE:	03/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Licensee/Administrator Eric Ruiz		TIME COMPLETED:	11:00 AM

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License Program Analyst (LPA) Hansen arrived announced to conduct a Required 1-year Infection Control Inspection of the facility. LPA was welcomed by Licensee Eric Ruiz. Facility has no residents at this time and licensee is leaving country for six to seven months while construction is completed on facility. Last resident was placed in other facility in December 2021.

LPA toured the facility at 10:00 am with licensee/administrator Eric Ruiz; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 9/2/2021 at the time of the visit. Smoke detectors and carbon monoxide detectors are wired by Bay Alarm and have been tested. Hot water temperature measured 114 degrees F. within Title 22 acceptable regulation of 105 to 120 degrees F. The facility serves residents with dementia and has a plan of operation for special care and programming. Toxins are stored in a locked closet on the hallway. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual fabric towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings.

Medications were centrally stored in locked closet above un-functioning oven in the kitchen.

Infection Controle:

Facility has submitted a mitigation program plan that has been approved, on 3/02/2022. All staff and visitors check in and log temperatures and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in hallway closet. Staff had all PPE training required as well have been N95 Fit Tested. All staff have received their COVID booster shots and all staff work exclusively at this facility.

Continued on 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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: SLEEPY HOLLOW VILLA	FACILITY NUMBER: 216803814
	VISIT DATE: 03/02/2022

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Facility conducts disaster drills quarterly with the last being 9/2021.

LPA reviewed Licensing Information System (LIS) with designee who stated that is correct and updated at this time; the only change at this time is to add Licensee’s cell number. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1^st Aid certification for staff.

As facility is under construction of new bathrooms and upgrades along with adding a safety cover to pool, licensee has been given a TA for reminder to put up fencing around pool and/or contact CCL for inspection prior to accepting any residents.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 3/15/2022 to RPRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC809 (FAS) - (06/04)

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