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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803356
Report Date: 10/18/2021
Date Signed: 10/18/2021 01:03:20 PM

Document Has Been Signed on 10/18/2021 01:03 PM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CORE ARF GADWALLFACILITY NUMBER:
286803356
ADMINISTRATOR:DADO,MYLENEFACILITY TYPE:
735
ADDRESS:3 GADWALL COURTTELEPHONE:
(707) 554-4802
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 2CENSUS: 2DATE:
10/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Mylene Dado, AdministratorTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lopez arrived unannounced to conduct an Annual Required inspection and met with Mylene Dado, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. LPA conducted Risk Assessment with Administrator.

Upon arrival, LPA observed facility with no posters outside entrance of facility pertaining to COVID-19 and advised Administrator to put up COVID-19 signs outside facility. LPA had temperature checked by Administrator but was not asked the screening questions and temperature was not documented at the entrance. LPA advised Administrator to add a sign-in sheet and have screening questions readily available. Administrator put the screening questions and sign-in sheet at the entrance.

LPA conducted a walk-through of the facility with Administrator and observed COVID-19 posters throughout the facility including hand washing posters in bathrooms. Hand sanitizer is available throughout the facility. Restrooms have hand hygiene products. The two clients were present at the time of visit and were both wearing surgical masks. Facility has submitted a mitigation program plan and was approved on 3/29/21. Facility has a 30-day supply of medication for clients. Facility has a designated visitation area. Facility has not conducted staff training on infection control and LPA advised facility to conduct training and document training. Clients currently do not attend in-person program but attend program virtually. Administrator stated that commonly touched surfaces are not disinfected daily and LPA advised them to disinfect high commonly touched surfaces at least once a day. Facility cleans facility daily. Facility has 30 day supply of Personal Protective Equipment (PPE) including but not limited to surgical and N-95 masks, gowns and hand sanitizer. Facility has a 100% vaccination rate of staff and clients are vaccinated.

During facility tour, LPA observed fire extinguishers were last charged in April 20, 2021. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. Hot tub in the back yard is covered and secure (LPA took photos of jacuzzi). LPA observed alcohol in refrigerator and Administrator immediately took out alcohol and locked it. (LPA took photos of alcohol)

Continue LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
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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Document Has Been Signed on 10/18/2021 01:03 PM - It Cannot Be Edited


Created By: Karen Lopez On 10/18/2021 at 11:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CORE ARF GADWALL
FACILITY NUMBER: 286803356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on tour, facility had two bottles of wine in refrigerator, the Administrator did not comply with the section cited above that LPA observed and Administrator removed immediately during visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2021
Plan of Correction
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Administrator will email or fax to LPA a statement that facility will not have any alcohol accessible to clients at any time.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Karen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2021


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: CORE ARF GADWALL
FACILITY NUMBER: 286803356
VISIT DATE: 10/18/2021
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The following deficiency will be cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator, Mylene Dado. Appeal Rights Given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC809 (FAS) - (06/04)
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