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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803969
Report Date: 11/03/2021
Date Signed: 11/03/2021 01:42:39 PM

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:ANNIE'S FAMILY HOME CARE OF CALISTOGAFACILITY NUMBER:
286803969
ADMINISTRATOR:VILLASENOR, SUSANNAFACILITY TYPE:
740
ADDRESS:1119 MITZI DR.TELEPHONE:
(707) 326-1994
CITY:CALISTOGASTATE: CAZIP CODE:
94515
CAPACITY:6CENSUS: 2DATE:
11/03/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Susanna Villasenor, LicenseeTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Lopez arrived unannounced to conduct a Post Licensing inspection and met with Licensee, Susanna Villasenor. LPA conducted a risk assessment with staff member. The inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

Upon arrival, LPA observed facility with posters outside entrance pertaining to COVID-19 and also advised facility to place poster regarding COVID-19 symptoms at the outside entrance. Facility put COVID-19 symptom signs at the entrance at the time of visit. LPA had temperature checked by staff member at the entrance and screening questions were on sign-in sheet.

LPA conducted a walk-through of the facility with Licensee and observed there were no COVID-19 posters inside the facility including hand washing posters in bathrooms. Facility put up signs in the facility during visit. Restrooms have hand hygiene products. Facility has a 30-day supply of medication for residents. 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. Facility disinfect high commonly touched surfaces at least multiples times a day. Facility cleans facility multiple times a day. Facility has 30 day supply of Personal Protective Equipment (PPE) including but not limited to surgical and N-95 masks, gowns, gloves and hand sanitizer. The facility has a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services.

During facility tour, LPA observed fire extinguishers were last charged in April 16, 2021. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. LPA noticed that two exit doors did not have a chime but room that exited out to the backyard did have one. Licensee agreed to add chimes to all exit doors and send proof to LPA by 11/5/21.

Continued on 809-C

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 7
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: ANNIE'S FAMILY HOME CARE OF CALISTOGA
FACILITY NUMBER: 286803969
VISIT DATE: 11/03/2021
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LPA noticed that there were cameras in the resident rooms and common areas with audio. LPA requested that the licensee submit their plan in writing to LPA if they decided to have video recording. LPA advised Licensee to remove cameras in bedrooms. Licensee removed cameras from bedrooms and common areas. Licensee purchased mats with an alarm system on 10/25/21 and will be using the mats instead of the cameras for resident bedrooms (LPA took copy of receipt). Facility will send proof to LPA of mats in residents rooms by 11/8/21.

At the end of visit Licensee had to leave and gave permission to staff member Carisma Patterson to sign the report.

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

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC809 (FAS) - (06/04)
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