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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803024
Report Date: 10/19/2021
Date Signed: 10/19/2021 10:32:30 AM

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:CRINELLA HOME CAREFACILITY NUMBER:
286803024
ADMINISTRATOR:GUTIERREZ, JUANAFACILITY TYPE:
740
ADDRESS:1726 CRINELLA DRIVETELEPHONE:
(707) 963-5289
CITY:ST. HELENASTATE: CAZIP CODE:
94574
CAPACITY:5CENSUS: 3DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Juana Gutierrez, AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Lopez arrived unannounced to conduct an Required- 1 year annual inspection and met with Administrator, Juana Gutierrez. LPA was greeted by staff and Administrator, Juana Gutierrez arrived shortly. The annual inspection was focused on the Infection Control procedures and practices. LPA conducted risk assessment with staff prior to visit.

LPA conducted a walk-through of the facility with Administrator. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on May 12, 2021. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. There was sufficient amount of supply for both perishable and nonperishable foods.

LPA observed COVID-19 precaution postings. A screening station was observed at front entrance of facility which had hand sanitizer, a thermometer, and a sign-in sheet for visitors and staff. Visitors and staff are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Resident's temperatures are taken twice a day. Staff clean and disinfect the facility daily. Administrator stated high touched surface areas are disinfected at least once a day. The facility has designated visitation areas, provides phone calls for family to stay in contact with residents.

LPA observed three residents in care. Staff have had some training on infection prevention, symptoms, transmission and PPE use but will provide more. The facility has a supply of PPE . The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was approved by the California Department of Social Services.

Exit interview conducted with Administrator, Juana Gutierrez whose signature on this document confirms receipt.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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