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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480110447
Report Date: 03/18/2022
Date Signed: 03/21/2022 10:13:06 AM

Document Has Been Signed on 03/21/2022 10:13 AM - 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:DELGADO ADULT RESIDENTIAL HOMEFACILITY NUMBER:
480110447
ADMINISTRATOR:KAMAL RAIFACILITY TYPE:
735
ADDRESS:123 ZINNIA CIRCLETELEPHONE:
(707) 647-0941
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Mahindra RaiTIME COMPLETED:
04:04 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with Mahindra Rai, Licensee. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. There is currently 4 clients in care.

LPA toured facility and grounds with licensee and observed some COVID-19 precaution signs posted in common areas but had no posters in the bathroom regarding promoting/proper hand washing. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. LPA was screened for temperature but there was no sign in sheet or Infection control questions asked. Facility Staff 2 of 2 were observed not wearing a mouth covering inside the facility or inside the van as they were going to go on an outing. The facility has a 30-day PPE supply. Facility to follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Facility understands hand sanitizer should not be placed in the rooms of clients who lack hazard awareness and impulse control. LPA observed facility has been providing Covid masks for all clients for outing and have explained Covid-19 precautions and how to use hand sanitizer. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was reviewed by the department on 9/6/2021. Caregivers have completed PPE training but have not been N-95 Fit tested.
In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged and serviced on 1/17/2022.

LPA requested facility staff to get N95 fit tested
Exit interview conducted with Mahindra Rai.

No deficiencies cited during today's inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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