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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801593
Report Date: 07/25/2022
Date Signed: 07/25/2022 10:23:58 AM


Document Has Been Signed on 07/25/2022 10:23 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:SAINT HELENA HOME CAREFACILITY NUMBER:
286801593
ADMINISTRATOR:GUTIERREZ, MARIA JUANAFACILITY TYPE:
740
ADDRESS:2011 OLIVE ST.TELEPHONE:
(707) 967-9549
CITY:ST. HELENASTATE: CAZIP CODE:
94574
CAPACITY:6CENSUS: 6DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee/Administrator, Maria Juana GutierrezTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required- 1 Year Inspection, and met with licensee Maria Juana Gutierrez. 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 licensee and observed COVID postings throughout. Infection Control Plan has been submitted to Community Care Licensing (CCL). Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. High touch surface areas are disinfected daily. Residents are monitored for COVID symptoms daily. LPA confirmed licensee has necessary personal protective equipment and supplies to support a resident in isolation. Facility has two shared bedrooms but a plan is in place to isolate COVID positive residents if necessary.

Residents' emergency contact information has been updated and licensee confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible. Medications are locked and inaccessible. Exit alarms on exit doors were working properly. Facility is conducting COVID-19 surveillance testing per CCL guidelines. All staff and residents are vaccinated and boosted

LPA reviewed 2 staff files and 2 resident files. LPA and licensee discussed training requirements. Licensee provided current CPR/First Aid for all staff. LPA requested updated copies of the following documents: Personnel Report (LIC 500), Resident Roster (LIC 9020), Designation of Facility Responsibility (LIC 308), Emergency Disaster Plan (LIC 610E)

No deficiencies cited during this inspection. Exit interview conducted with administrator and a copy of this report left for the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
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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