<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800667
Report Date: 11/18/2022
Date Signed: 11/18/2022 10:58:15 AM


Document Has Been Signed on 11/18/2022 10:58 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:CEDARS CARE HOME, THEFACILITY NUMBER:
286800667
ADMINISTRATOR:LOPEZ, PAULINAFACILITY TYPE:
740
ADDRESS:1520 CEDAR STREETTELEPHONE:
(707) 942-9200
CITY:CALISTOGASTATE: CAZIP CODE:
94515
CAPACITY:12CENSUS: 5DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Viridiana AgapoffTIME COMPLETED:
11:05 AM
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) Erik Gonzalez Campos arrived unannounced on 11/18/2022 to conduct a Required - 1 Year inspection, and met with administrator, Viridiana Agapoff. The inspection is focused on the Infection Control procedures and practices of this facility.

LPA was greeted by staff. Upon entry LPA was screened for COVID symptoms and asked to sign in. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of facility with administrator and observed COVID postings throughout. Infection control plan has been submitted and reviewed by Community Care Licensing (CCL). Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Staff have completed Personal Protective Equipment (PPE) and infection control training. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPA confirmed licensee has necessary equipment and supplies to support a resident in isolation. Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible. Medications are centrally stored and kept secured. All staff and residents are fully vaccinated and boosted. LPA and administrator discussed the annual servicing of fire extinguishers.

LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection: LIC 500 Personnel Report, LIC 9020 Resident Roster, LIC 308 Designation of Facility Responsibility, LIC 610 Emergency Disaster Plan, Evidence of Liability Insurance, LIC 200 Application (Admin Change), LIC 501 Personnel Record

No deficiencies cited during today's inspection. Exit interview conducted with administrator and a copy of the report printed for the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1