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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480109151
Report Date: 05/20/2022
Date Signed: 05/26/2022 01:25:16 PM

Document Has Been Signed on 05/26/2022 01:25 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:MC KINLEY CARE HOMEFACILITY NUMBER:
480109151
ADMINISTRATOR:MC KINLEY, BARBARAFACILITY TYPE:
735
ADDRESS:186 KEMPER STREETTELEPHONE:
(707) 557-2152
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Barbara McKinley, LicenseeTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by Licensee, Barbara McKinley. The facility currently provides care for five clients, four of which were present at the time of visit and one of which was admitted in the hospital for expected transfer to a more appropriate facility. There were 2 staff present at the time of visit, sufficient for the 3:1 staff to client ratio.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator and facility staff; facility was found to be clean and at a comfortable temperature. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 5/21/2021 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. There was a supply of linens, hygiene products and paper products available for clients located in the hallway. All client’s bedrooms have lighting & appropriate furnishings. Hot water measured between 123.8 and 125 degrees F which is not within Title 22 regulations of 105 to 120 degrees F in faucets used by clients. However, signs are posted at each faucet used by clients clearly indicating water is over 120 degrees F. Licensee explained to LPA that the clients prefer the water to be slightly warmer. All staff have updated 1st Aid & CPR Training on file.

LPA observed one (1) fence panel along the backyard to be loose and in need of repair. LPA issued Technical Violation and Licensee agrees to have the repairs conducted the same day 5/20/2022.

Continued onto LIC809(C)**
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MC KINLEY CARE HOME
FACILITY NUMBER: 480109151
VISIT DATE: 05/20/2022
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LPA requested the following documents be sent to CCL by COB 5/27/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Certificate of Liability Insurance

Infection Control:
Facility has submitted a mitigation program plan which has been approved. All staff and clients have been vaccinated with no reported or observed symptoms. Posters have been placed at the front door, and facility has a station at main entrance with a sign in, hand sanitizer and other items designated for visitors and staff. Staff are screened for temperature and symptoms on a daily basis and clients are screened on a daily basis.


No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC809 (FAS) - (06/04)
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