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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392790075
Report Date: 11/02/2020
Date Signed: 10/08/2021 02:28:28 PM

Document Has Been Signed on 10/08/2021 02:28 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HAYNES BOARD AND CAREFACILITY NUMBER:
392790075
ADMINISTRATOR:PARKER, CHERYLFACILITY TYPE:
735
ADDRESS:17201 N. TULLY ROADTELEPHONE:
(209) 727-5834
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 30CENSUS: 21DATE:
11/02/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator Sandra HaynesTIME COMPLETED:
04:30 PM
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On 11/2/2020 at 3:30pm Licensing Program Analyst (LPA) Kevin Gould and Managers Czarrina Camilon-Lee and Krystall Moore conducted a tele-case management inspection with Haynes Board and Care to address COVID 19 mitigation measures currently in place at the facility. LPA Gould and managers met with Administrator Sandra Haynes and together discussed plans currently in place to prevent spread of COVID and to ensure isolation of residents is being conducted in a manner consistent department infection control policies.

Joining on the tele-inspection are Veronica Nazareth, HFEN; Brain Bennett, VMRC; Kasie Gee, DDS Nurse; and Pam Costamagna, SJCPH.

Administrator conducted a video tour of the facility including front entrance and screen station, communal areas, socially distanced seating arrangements, community bathrooms, COVID isolation area including resident rooms, bathrooms and separate entrance. All parties provided feedback for administrator and together agreed to the following actions: Administrator will provide LPA Gould with weekly staff schedule, COVID mitigation plan by end of business 11/3/2020. Administrator will also provide isolation plan for non-lab confirmed, suspected COVID positive persons outside of the specific COVID isolation wing of facility by today. A plan will provide isolation procedures for positive residents and person under investigation for COVID by today.

Kasie Gee will work with Administrator to identify possible regional center surge homes as a possible placement for residents requiring COVID Isolation. Regional Office will provide facility with an additional 100 disposable gowns scheduled to be delivered to the facility on Wednesday, 11/4/2020.

A copy of this report will be mailed to the facility for signature.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2020
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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