216803951-9-1-2021-21-AS-CFGS-C6FKK8-20210901075756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803951
Report Date: 08/31/2021
Date Signed: 09/01/2021 07:58:13 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 NOVATO		FACILITY NUMBER:	216803951
ADMINISTRATOR:	ACUMABIG, JOSE		FACILITY TYPE:	740
ADDRESS:	516 E. HOSPITAL RD		TELEPHONE:	(410) 427-2700
CITY:	NOVATO	STATE: CA	ZIP CODE:	94949
CAPACITY:	95	CENSUS: 15	DATE:	08/31/2021
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Jose Acumabig - Executive Director		TIME COMPLETED:	05:25 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 an unannounced post-licensing inspection to this facility and was welcome by Jose Acumabig - Executive Director. Facility has 15 residents at this time. LPA arrived at the facility and observed hand sanitizer at the entrance. Facility has a log in binder for temperature of visitors and answering questionnaire. During tour the facility on 08/31/2021 with Executive Director Jose Acumabig, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample tour of resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 8/20. Hot water temperature measured between 113.7 degrees F and 118.2 degrees F in 3 out of 3 resident’s bathroom faucets which are within Title 22 acceptable regulation of 105 to 120 degrees F. Toxins are stored in a locked housekeeper storage. Dangerous items were stored inaccessible to develop disabled residents. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available. Sample resident’s bedrooms have lighting & appropriate furnishings. 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 & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19) Infection Control: Facility has submitted a mitigation program plan that has been approved at this time. Posters have been placed at facility entrance and masks are available. Facility has PPE supply stored in the facility 2^nd floor storage closed. Facility has hired and admitted new staff and residents since COVID-19. Resident’s medications are stored and locked in medication room. Continue LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

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: ELEGANCE AT NOVATO	FACILITY NUMBER: 216803951
	VISIT DATE: 08/31/2021

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Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Facility still working towards acquiring N-95 fit testing.

LPA reviewed Licensing Information System (LIS) with Executive Director who stated that there has been a change of street name, facility number, and facility name. ED will be submitting an LIC 200 with documentation for all the changes to be in effect. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster drills have been conducted.

Department is requesting the following to be submitted to CCLD by 9/10/2021:
LIC 200 - for changes
LIC 500
LIC 9020
Copy of liability insurance

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC809 (FAS) - (06/04)

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