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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708925
Report Date: 09/23/2021
Date Signed: 09/23/2021 03:06:31 PM

Document Has Been Signed on 09/23/2021 03:06 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,
, CA
FACILITY NAME:ST. CHARLES GUEST HOMEFACILITY NUMBER:
270708925
ADMINISTRATOR:TUMACDER, ELENAFACILITY TYPE:
740
ADDRESS:707 ST. CHARLES WAYTELEPHONE:
(831) 758-5145
CITY:SALINASSTATE: CAZIP CODE:
93905
CAPACITY: 6CENSUS: 6DATE:
09/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Janet LapitanTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Janet Lapitan Administrator.

LPA toured the facility inside and out to include entry, kitchen, dining, bathroom and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in a locked medication cabinet in the kitchen. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathroom observed to be supplied with hygiene products and hand washing signs posted. Hand sanitizer available to residents and visitors. LPA observed supply of Personal Protective Equipment (PPE).

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, staffing, training, supplies, PPE usage, Donning and Doffing of PPEs, Fit Testing, and social distancing.

RO to provide additional supply of PPEs to include N95s, surgical masks, gowns and gloves.

LPA to forward informational links for posters, PPE Donning and Doffing and EPA recommended disinfecting products.

No deficiencies cited per the California Code of Regulations Title 22.

LPA reviewed report with Janet Lapitan Administrator and a copy of this report provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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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