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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803889
Report Date: 03/15/2022
Date Signed: 03/16/2022 09:18:31 AM

Document Has Been Signed on 03/16/2022 09:18 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:FILIA HOME CAREFACILITY NUMBER:
216803889
ADMINISTRATOR:ANGLADE, JUDITHFACILITY TYPE:
735
ADDRESS:1 ARBOR CIRCLETELEPHONE:
(415) 493-6104
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 3DATE:
03/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Judith Anglade - Licensee/AdministratorTIME COMPLETED:
03:25 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 licensee/administrator Judith Anglade. One client arrived during this visit, 1 client was in the facility, and 1 client was in an outing. There are activities planned for clients during the day if they want to participate.

During facility tour on 03/15/2022 with licensee/administrator Judith Anglade, 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. Carbon monoxide detector and Smoke detectors test 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 closet in kitchen cabinet. 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 faucet measured 115.3 degrees F in 1 out of 1 faucet within Title 22 acceptable regulations of 105 to 120 degrees F. Disaster Drills was last conducted on 6/2/2021. Disaster drills have been conducted every six months and last drill was on 9/21/21

Continued LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
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: FILIA HOME CARE
FACILITY NUMBER: 216803889
VISIT DATE: 03/15/2022
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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 is at entrance. Facility has PPE supply stored in hallway closet. There has been new staff hired and new clients since COVID-19/facility was licensed. Clients’ medications are stored and locked in medication cabinet in kitchen area. 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 and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and facility has acquired N-95 fit testing.

There were no deficiencies cited at this time.

Department is requesting Licensee to update the following documents and submit to CCL by 3/22/2022:

LIC 308 Designated Administrator
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
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC809 (FAS) - (06/04)
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