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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800302
Report Date: 04/26/2022
Date Signed: 04/26/2022 02:20:23 PM


Document Has Been Signed on 04/26/2022 02:20 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: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: 5DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Staff, Joti Ann ZulitaTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Katrina Walters arrived at Good Samaritan Care Home for the purpose of conducting an unannounced Required-1 Year inspection. LPA met with Staff, Joti Ann Zulita and was granted access into the facility. This visit will focus on the infection control of this facility.

There was a sign posted at the entrance of the facility that requested visitors not enter if they're presenting any symptoms of COVID-19. Once LPA was granted entrance, staff checked LPAs temperature and had LPA sign in on guest book. The facility was clean and a comfortable temperature. All client's bedrooms were clean, had appropriate lighting, and furnished as required per regulation. Per staff, the facility is disinfected twice daily and as needed. There was at least a 30 day supply of incontinence products for residents. LPA reviewed staff files and observed infection prevention and personal protective equipment (PPE) training for staff. A separate binder stored all resident and staff records, along with additional COVID training's for staff.

Smoke detectors, Carbon Monoxide detectors and sprinklers were tested and appeared to be operational. Fire Extinguishers were last serviced 10/08/2021.

The facility previously submitted a mitigation plan that was approved by Community Care Licensing, but since then there have been updated regulatory requirements related to infection control prevention and mitigation for communicable diseases. LPA is requesting that the facility submits an updated mitigation plan by 6/30/22. LPA provided a copy of new requirements in PIN 22-13 ASC. No deficiencies were observed or cited during this inspection. Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
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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