286803581-8-16-2021-21-AS-AELT-C5XPDE-20210816111325

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803581
Report Date: 08/16/2021
Date Signed: 08/16/2021 11:13:32 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:	C&F SENIOR CARE HOME AMERICAN CANYON		FACILITY NUMBER:	286803581
ADMINISTRATOR:	FOJAS, LINA		FACILITY TYPE:	740
ADDRESS:	178 SONOMA CREEK WAY		TELEPHONE:	(707) 246-0867
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	94503
CAPACITY:	5	CENSUS: 2	DATE:	08/16/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lina Flojas		TIME COMPLETED:	11:30 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) Angela Elliott conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Licensee Lina Flojas. Facility has 2 residents. Facility offers activities of morning exercise, walking, being in the backyard and IPad activities. During facility tour, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Licensee indicated facility had not had a recent Fire Safety Inspection. Fire Extinguisher was last inspected on 3/26/2021. Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. LPA issued a Technical Assistance for Fire Safety Inspection. Disaster Drills were current. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Dangerous items were stored inaccessible to residents in a locked drawer in the kitchen. There was a supply of cleaners, hygiene products and paper products available for residents. The residents bedroom did not have chairs for the two residents in care. Licensee explained they move the chairs around and put them back in the residents bedroom during inspection. LPA issued a Technical Assistance. LPA printed a copy of the Personal Accommodations and Services regulations. Hot water temperatures measured between 105 degrees and 120 degrees F within Title 22 acceptable range. Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into the facility. Facility has PPE supplies stored in a closet. Hygiene supplies are stored in a locked closet in the facility and a locked cabinet out in the garage. Facility has a 30-day supply of medication for residents and they are kept in a locked cabinet in the kitchen. All staff had masks on during this visit. Continued LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021

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: C&F SENIOR CARE HOME AMERICAN CANYON	FACILITY NUMBER: 286803581
	VISIT DATE: 08/16/2021

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In addition, facility has a designated areas for visitors which are being allowed for scheduled visits. Residents also have available Facetime and telephone calls when contacting family members and others. Staff have received COVID-19 and Infection Control Training. According to Licensee staff have had PPE training and have obtained N-95 fit testing. LPA recommended Licensee follow up with agencies that provided training to get proof of training.

LPA advised facility to contact local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + cases in the facility.

LPA had a discussion with Licensee regarding guidelines per PIN-21-32.1. LPA confirmed Licensee gets PIN’s automatically via email.

LPA requested date of fire safety inspection be sent to LPA by COB 8/18/2021 and proof of inspection when complete. There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021

LIC809 (FAS) - (06/04)

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