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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803951
Report Date: 06/14/2021
Date Signed: 06/15/2021 09:49:30 AM

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:ELEGANCE AT NOVATOFACILITY NUMBER:
216803951
ADMINISTRATOR:ACUMABIG, JOSEFACILITY TYPE:
740
ADDRESS:516 E. HOSPITAL RDTELEPHONE:
(410) 427-2700
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY:95CENSUS: 0DATE:
06/14/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jose Acumabig - Executive DirectorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted a pre-licensing inspection and met with Executive Director Jose Acumabig. Fire clearance has been approved for 81 Non-ambulatory and 14 bedridden residents by the Marin County Fire Department. LPA will conduct a component III orientation with Jose Acumabig Executive Director, Veronica Gonzalez, Ron Villacis – Regional Manager.

LPA toured facility and observed: Facility is four floors, in good repair and at a comfortable temperature. Hot water temperature checked between 118.5 and 120.0 degrees F in 5 out of 5 resident's faucets as required by Title 22 Regulations. The facility has a phone line designated for residents' use. Personnel and residents' records are stored at the facility office. Facility plans on having awake staff.

The building includes kitchen, dining area, activities area, bar and lounge, lobby, beauty salon, bistro, discovery room/visitation room, laundry room, office rooms, medication room, Memory Support and Assisted Living resident's bedrooms, and terrace. Facility plans on having several different activities available for residents as desired and has an activity calendar posted. There is outdoor space for activities. Menus for dining are posted on the board and place on dining table. Special diets will be posted on a kitchen board and will have a binder for special diets. Toxins will be locked in housekeeper room on first floor. Facility also has community restrooms downstairs. Postings noted to be current and in compliance with guidelines. Locked cabinets for sharps and daily used toxins. First aid kit has been placed in few different areas of the facility. PPE is being stored in a supply room.

Facility is pending approval of Mitigation Program Plan for licensure.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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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