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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 230111889
Report Date: 09/26/2022
Date Signed: 09/26/2022 12:00:20 PM


Document Has Been Signed on 09/26/2022 12:00 PM - 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:DALISTAN CARE HOME IIFACILITY NUMBER:
230111889
ADMINISTRATOR:DALISTAN, PAZ VICTORIAFACILITY TYPE:
740
ADDRESS:208 SCOTT STREETTELEPHONE:
(707) 468-9329
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:12CENSUS: 11DATE:
09/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:John DalistanTIME COMPLETED:
12:15 PM
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At approximately 10:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an Annual Required infection control inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPA met with Administrator John Dalistan. There were 11 residents present at the facility.

LPA arrived at the facility and had temperature checked and health questions asked. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged and inspected within the last 12 months. Toxins are stored and not accessible. There was a supply of cleaners, hygiene products and paper products available for resident use.

Facility has submitted an infection control plan. Posters are in place at the entrance and throughout the building. The entrance area has a small table with hand sanitizer, thermometer and other items designated for visitors and staff before coming into work or visit. Facility has PPE supplies. Medications are secure and not accessible to residents. Facility has reviewed and submitted a Emergency Disaster plan. Residents do not typically wear masks inside the facility but have them available. LPA observed all staff wearing masks during this visit.

LPA received certificate of liability coverage.


There were no deficiencies found in the areas inspected.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022
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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