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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202689
Report Date: 05/09/2022
Date Signed: 05/09/2022 10:50:10 AM


Document Has Been Signed on 05/09/2022 10:50 AM - 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:SONGBIRD IN THE COUNTRYFACILITY NUMBER:
275202689
ADMINISTRATOR:MAZIREK, BETHFACILITY TYPE:
740
ADDRESS:15961 TORO HILLS AVENUETELEPHONE:
(831) 998-8708
CITY:SALINASSTATE: CAZIP CODE:
93908
CAPACITY:12CENSUS: 10DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Matt Mazerik TIME COMPLETED:
11:05 AM
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On 05/09/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Haixa Garcia and Suchilla “Suchie” Navarro, Caregivers. Administrator Matt Mazerik and Care coordinator Sheila Gonzalez was called and arrived shortly and conduct tour with LPA. All ten residents were present during the inspection.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings. LPA observed fire extinguisher served date: 02/10/22.

Cleaning supplies were stored and locked under kitchen sink and back storage room. LPA checked residents’ locked medications. Food supply was checked and appeared to be an adequate supply. LPA observed 30 days of PPE supplies. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 4 shared residents’ bed to be at least 6 feet apart and 2 single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. LPA observed all bathroom trash bin with no lid. Hand washing posting observed by bathroom sinks. The exterior tour was conducted. Outside free of obstruction. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All ten resident records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 05/16/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Lic 808, Lic 9020, and current liability insurance. LPA received copy of current Administrator certificate. A copy of this report was provided to Administrator.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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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