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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800164
Report Date: 06/28/2022
Date Signed: 06/28/2022 01:06:27 PM

Document Has Been Signed on 06/28/2022 01:06 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:CLARK-RO RESIDENTIAL CARE IIFACILITY NUMBER:
486800164
ADMINISTRATOR:SKILLMAN, ROSIE L.FACILITY TYPE:
735
ADDRESS:1234 LOUISIANA STREETTELEPHONE:
(707) 643-3567
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 0DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Judy Johnson, Lead StaffTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Lead Staff, Judy Johnson (JJ). The facility currently has 0 clients in care. The facility is in contact with North Bay Regional Center for vendorization and is expected to admit clients within the next 2-3 months. The Licensee will keep LPA updated on facility operations.

LPA arrived at the facility and had temperature checked and logged. The facility is currently under renovations with expectations to be completed before re-opening of operation. LPA continued with a tour of the facility with Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

Infection Control:
Facility has submitted a COVID Infection Control Plan for review. Posters are readily available and will be posted once the facility is back in operation. Facility has a station at main entrance with a sign in sheet in place, hand sanitizer and other items designated for visitors and staff. Staff and residents will be screened on a daily basis once admitted.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 7/5/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
Copy of Administrator Certificate(s)
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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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