286801593-6-22-2021-21-AS-EGCS-C48R2D-20210622123810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286801593
Report Date: 06/22/2021
Date Signed: 06/22/2021 12:39:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	SAINT HELENA HOME CARE		FACILITY NUMBER:	286801593
ADMINISTRATOR:	GUTIERREZ, MARIA JUANA		FACILITY TYPE:	740
ADDRESS:	2011 OLIVE ST.		TELEPHONE:	(707) 967-9549
CITY:	ST. HELENA	STATE: CA	ZIP CODE:	94574
CAPACITY:	6	CENSUS:	DATE:	06/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Maria Juana Gutierrez		TIME COMPLETED:	12:45 PM

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 Analysts (LPA), Angela Elliott and Erik Gonzalez Campos arrived unannounced to conduct an Annual inspection at approximately 11:30AM, and met with licensee Maria Gutierrez (Juana). The inspection is focused on the Infection Control procedures and practices of this facility. LPAs were greeted by licensee. Upon entry LPAs were screened for COVID symptoms and asked to sign in. At primary entrance LPAs observed temperature logs and visitor sign-in sheet. LPAs conducted walk through of facility with licensee and observed COVID postings throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL). Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per licensee, they regularly discuss infection control and PINs with residents and staff. Changes in protocol are communicated to responsible parties via phone or text message. Staff have completed Personal Protective Equipment (PPE), infection control training but have not been N-95 Fit tested. Licensee was unable to provide documentation of training related to PPE and N95 fit testing. LPAs suggested licensee request documentation of PPE training from home health. Facility is cleaned daily and high touch surfaces are cleaned twice a day. Due to current facility census, residents could isolate in their own rooms if they became ill. LPAs confirmed licensee has necessary PPE equipment and supplies to support a resident in isolation. (Continued on LIC 809-C)

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SAINT HELENA HOME CARE	FACILITY NUMBER: 286801593
	VISIT DATE: 06/22/2021

NARRATIVE

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LPAs requested to see temperature screening logs and determined they were current. Residents' emergency contact information has been updated and licensee confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked cabinets under the sinks. Medications are stored in a locked hallway closet making them inaccessible to residents and facility had a 30 day supply of medications. The facility has a large supply of Personal Protective Equipment (PPE) and hygiene supplies located in the garage. All exit alarms on exit doors were working properly. Facility is conducting COVID-19 surveillance testing per CCL guidelines. Licensee stated that the facility is following and operating in compliance with their approved mitigation plan.

Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. LPAs and licensee discussed client activities and visitation. Currently visits are happening daily both inside and outside of the facility. Licensee confirmed residents are screened upon returning from outings. LPAs discussed group activities with licensee which include chair exercises, exercise videos, piano playing, and music.

Licensee and LPAs discussed their Emergency Disaster Plan and confirmed it is current.

LPAs reviewed lease of property information with licensee. Licensee agrees to provide current lease agreement information to LPA by June 25, 2021. LPAs were provided current copy of the administrator certificate.

LPAs unable to print, will email report and supporting documentation to licensee.

No deficiencies cited during this inspection

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC809 (FAS) - (06/04)

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