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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236801775
Report Date: 08/24/2023
Date Signed: 08/24/2023 02:43:14 PM

Document Has Been Signed on 08/24/2023 02:43 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:EQUINOX CARE FACILITY LLCFACILITY NUMBER:
236801775
ADMINISTRATOR:AJEL, AGNESFACILITY TYPE:
740
ADDRESS:38281 S HWY 1TELEPHONE:
(707) 884-4061
CITY:GUALALASTATE: CAZIP CODE:
95445
CAPACITY: 9CENSUS: 5DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Agnes AjelTIME COMPLETED:
03:00 PM
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At approximately 12:15PM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Administrator Agnes Ajel. At approximately 12:30PM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.

At approximately 12:45PM, LPA reviewed 5 of 5 resident records. All records contained current and signed admission agreements and current physician reports. Medication records are thorough and contained physician's orders for each resident. 3 residents are receiving Hospice services and the Hospice care plans were up to date for each resident.

At approximately 1:30PM, LPA reviewed 3 staff records. All records contained evidence of completed training as required. Evidence of current first aid and CPR training were current. LPA interviewed 2 staff during this inspection.
Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: EQUINOX CARE FACILITY LLC
FACILITY NUMBER: 236801775
VISIT DATE: 08/24/2023
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At approximately 2:00PM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 8/21/2023.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

Evidence of Control of Property
Evidence of Liability Insurance

No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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