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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202713
Report Date: 12/14/2021
Date Signed: 12/15/2021 06:42:11 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:RACHELLE'S HOME IFACILITY NUMBER:
445202713
ADMINISTRATOR:RECINTO, RACHELLEFACILITY TYPE:
740
ADDRESS:99 AIRPORT BLVDTELEPHONE:
(831) 319-4190
CITY:FREEDOMSTATE: CAZIP CODE:
95019
CAPACITY:12CENSUS: 9DATE:
12/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Rachelle RecintoTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Rachelle Recinto Administrator/Licensee.

LPA toured the facility inside and out to include entry, kitchen, dining, living room, bedrooms, bathrooms, laundry room, and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in a locked medication cart and refills are stored in a locked medication cabinet. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening with questionnaire. Signs posted included Symptoms of COVID 19, Germs, Cough Etiquette, Droplet Precautions, Cleaning for COVID and How Can I Protect Myself. Bathrooms observed to be supplied with hygiene products. Hand washing signs posted. Hand sanitizer available to residents and visitors. LPA observed supply of Personal Protective Equipment (PPE). All staff have been FIT Tested for N95 masks.

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, sick leave polices, training, and PPE usage.

No citations issued per the California Code of Regulations Tittle 22.

LPA reviewed report with Rachelle Recinto Administrator/Licensee and a copy of this report provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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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