216803899-8-11-2020-21-AS-CFGS-BSDVZ7-20200811165216

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803899
Report Date: 08/11/2020
Date Signed: 08/11/2020 04:53:08 PM

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:	BEL MARIN GARDENS		FACILITY NUMBER:	216803899
ADMINISTRATOR:	LOCKERBIE, LAARNI UY		FACILITY TYPE:	740
ADDRESS:	119 MONTEGO KEY		TELEPHONE:	(628) 259-2954
CITY:	NOVATO	STATE: CA	ZIP CODE:	94949
CAPACITY:	6	CENSUS: 4	DATE:	08/11/2020
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Laarni Lockerbie - Licensee/administrator		TIME COMPLETED:	12:00 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 a tele-visit inspection on 8/11/2020 at approximately 9:50 AM to conduct a post licensing visit. LPA is conducting a tele-visit with Administrator/Licensee Laarni Lockerbie. The inspection is being conducted by tele-inspection due to COVID-19. The reader is advised that the LPA did not physically make a site visit. Currently there are 4 residents in care. There are no residents under hospice care or with a dementia diagnostic at this time. LPA observed auditory device functioning on the front door at the time of the tele-visit. LPA observed facility seem to be clean and with all exits free from obstruction. Exits were equipped with auditory devices. Fire Extinguisher as per licensee was last charged on 8/2021 at the time of the visit. Smoke detectors and carbon monoxide detectors were tested and found to be operational during the visit. Licensee was able to provide LPA with a water temperature reading of 103. degrees F and 113 degrees F following of Title 22 acceptable regulation of 105 to 120 degrees F in 1 of 3 resident’s faucets. Facility will monitor the bathroom to ensure compliance. Bathrooms were equipped with necessary grab bars and non-slip floors/mats and appeared to have sufficient hygiene products. The amount of fresh and nonperishable foods appeared to be within Title 22 Regulation. Food stored in the kitchen refrigerator were properly stored as per regulations during tele-visit. Food is available for residents any time of the day. Toxins and medications appeared to be in locked cabinets in the kitchen and laundry. LPA observed required postings (LTCO, CCL Complaint poster). Facility is screening essential visitors at the front door which includes taking temperatures and requiring visitors to wear masks. continue LIC 809-C

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020

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: BEL MARIN GARDENS	FACILITY NUMBER: 216803899
	VISIT DATE: 08/11/2020

NARRATIVE

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LPA and Licensee inspected via tele-visit the back-yard area. In addition, LPA reviewed resident’s files through tele-visit which only allowed LPA to observe forms, signature, and dates as current shelter in place only allows for essential visits at this time. Licensee states there are no residents admitted with prohibited conditions and that 1/2 rail orders are on file for those with the postural supports. Licensee furthers states that all needs/service plans and appraisals are up to date.

LPA reviewed 2 staff record and found that staff had current 1st aid / CPR and training and both have and Administrator Certificate – Aira Monte # 6056005740 expires on 12/31/2020 and Laarni Lockerbie # 6025647740 expires on 4/12/2021.

Licensee stated disaster drills are conducted quarterly with the last drill conducted 5/25/2020.

No deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020

LIC809 (FAS) - (06/04)

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