216803982-11-16-2021-21-AS-CFGS-C8TLA4-20211116073430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803982
Report Date: 11/15/2021
Date Signed: 11/16/2021 07:34:42 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:	ANTON POINTE, THE		FACILITY NUMBER:	216803982
ADMINISTRATOR:	ODIWE, CLEDA M.		FACILITY TYPE:	740
ADDRESS:	1470 SOUTH NOVATO BLVD.		TELEPHONE:	(415) 897-1055
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	10	CENSUS: 7	DATE:	11/15/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Cleda Odiwe - Licensee/Administrator		TIME COMPLETED:	01:45 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 pre-licensing inspection and met with Licensee/Administrator Cleda Odiwe. This is a change of ownership. Fire clearance has been approved for 10 non-ambulatory residents by the County Fire Department. LPA will conduct a component III orientation with Cleda & Ken Odiwe Administrator/Licensee. There is a total of 7 residents and no residents under Hospice care. Facility tour/inspection began at 10:45 AM: Facility is a one floor facility. LPA toured the facility on 11/15/2021 with Licensee/Administrator Cleda Odiwe; facility was found to be at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 06/2021. Sample test of facility smoke detectors and carbon monoxide detectors were found to be operational. Sample hot water temperature measured 111.7 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 1 of 1 resident’s bathroom faucet. The facility has special care plan of operation and programming for residents with dementia. Facility does grocery shopping on Tuesdays. Food stored in the kitchen refrigerator were properly stored as per regulations. LPA observed that provisions are made for individuals with special dietary needs. Food is available for residents any time of the day. Toxins are stored in a locked cabinet in the office room. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

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: ANTON POINTE, THE	FACILITY NUMBER: 216803982
	VISIT DATE: 11/15/2021

NARRATIVE

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Facility floor includes kitchen, laundry room, living room area, bathrooms, office room, dining room, and resident's bedrooms, and bathrooms. There is outdoor space for activities. Resident's & Personnel records, medication, first aid supplies, and toxins will be locked in the office. Postings noted to be current and in compliance with guidelines. First aid kit has been placed by medications. PPE is being stored in a supply room. Disaster Drills have been conducted often and in different shifts with the last one being conducted on 7/2021.

Community Care Licensing has requested the following items be corrected prior to licensure: (LPA will be revisiting facility unannounced after licensee communicates that facility is ready for a visit.)

- Facility must be in good repair: facility need to have walls clean/painted, carpet needs to be repair and clean, residents bedrooms missing night stands and lamps, ceiling in the living room coming off and spots of water stain, resident's bedroom shades; outside area to have any tripping hazards.
- Post the following: Calendar for plan activities, resident's personal rights, and non-discrimination notice.
- Proof of quarterly disaster drill - last was 7/2021.
- Request for underage resident exception - pre-assessment, LIC 602, letter from POA, letter from facility requesting underage exception with name and DOB for resident. (due on 11/19/2021)

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: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

LIC809 (FAS) - (06/04)

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