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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480111090
Report Date: 04/26/2022
Date Signed: 04/27/2022 11:09:11 AM

Document Has Been Signed on 04/27/2022 11:09 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:GILCREST GROUP HOME, THEFACILITY NUMBER:
480111090
ADMINISTRATOR:CHERYL DAVIDSONFACILITY TYPE:
735
ADDRESS:447 GILCRESTTELEPHONE:
(707) 563-5543
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 9CENSUS: 5DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Cheryl DavidsonTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with staff, Clora Lindsay, Administrator, Cheryl Davidson arrived a few minutes later. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. There is currently 5 clients in care and this facility is licensed for a total capacity of 9 Ambulatory clients, no approval for non-ambulatory or bedridden clients.

LPA toured facility and grounds and observed COVID-19 precaution signs posted in common areas to promote hand washing. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices that are present: entry procedures, sign-in, daily monitoring and temperatures checked for clients and staff, and 30-day PPE supply. Facility will 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. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was submitted to the department on 8/16/2021. Caregivers have completed PPE training but have not been N-95 Fit tested.
In addition, facility was found to be clean, at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged and serviced on 6/17/2021.

LPA went over incident for client C1 who tripped going up the stairs, fell and fractured their arm. C1 had to have surgery and has been out the facility in rehab, Facility to send in additional information.

Exit interview conducted with Cheryl Davidson

No deficiencies cited during today's inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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