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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803581
Report Date: 09/09/2022
Date Signed: 09/09/2022 01:09:07 PM


Document Has Been Signed on 09/09/2022 01:09 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:C&F SENIOR CARE HOME AMERICAN CANYONFACILITY NUMBER:
286803581
ADMINISTRATOR:FOJAS, LINAFACILITY TYPE:
740
ADDRESS:178 SONOMA CREEK WAYTELEPHONE:
(707) 246-0867
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY:5CENSUS: 5DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Lina FojasTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 09/09/2022 to conduct a Required Year Inspection. LPA was initially greeted by staff. Administrator, Lina Fojas arrived shortly. This inspection is focused on the infection control practices and procedures of this facility.

LPA toured building and grounds with administrator which were found to be clean and in good repair. Resident bedrooms are located on the first floor. Care staff rooms are located on the second floor. Walkways and exits were free from obstructions. The amount of fresh and non-perishable food was within regulation. Medications were centrally stored and locked. Toxins were secured and inaccessible to residents in care. Facility has conducted infection control training with staff and is in the process of N95 fit testing. High touch surface areas are disinfected daily. Facility monitors residents for COVID symptoms daily, administrator provided log. Visitors are screened upon entry, LPA observed log at front entrance. All residents and staff are fully vaccinated and boosted. LPA and administrator discussed regulation regarding required furnishings.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610E- Disaster Plan
Evidence of Liability Insurance
LIC 9020- Resident Roster

Exit interview conducted with administrator, Lina Fojas and a copy of this report was printed for the facility.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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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