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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800302
Report Date: 06/16/2021
Date Signed: 06/16/2021 02:00:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GOOD SAMARITAN CARE HOME, THEFACILITY NUMBER:
486800302
ADMINISTRATOR:GARCIA, BRENDA C.FACILITY TYPE:
740
ADDRESS:506 LABRADOR WAYTELEPHONE:
(707) 718-0498
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:6CENSUS: 4DATE:
06/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Brenda GarciaTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Walters and Nakagawa conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was greeted by staff. Administrator, Brenda Garcia arrived later. LPAs conducted a Risk Assessment with Administrator. There were 2 staff providing care and supervision for 4 residents.

Upon entry, LPAs were screened for COVID-19 symptoms and temperatures were checked. LPAs/Staff conducted a tour through the facility and observed that the facility was clean and a comfortable temperature and passageways were free from obstructions. Signs were posted throughout the facility to promote hand washing and social distancing. Resident rooms were furnished per regulation. Extra hygiene products and cleaning products were available. Facility is able to designate a single isolation room for any asymptomatic or symptomatic residents in the event of an outbreak. Residents and staff temperatures are checked daily and logged in a binder.

Facility has submitted a mitigation program plan that was approved on 4/21/21. Facility has PPE supplies stored in garage cabinets. Facility has conducted staff training on infection control.

No deficiencies were cited during today's inspection.

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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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