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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800471
Report Date: 05/26/2022
Date Signed: 05/26/2022 03:06:56 PM

Document Has Been Signed on 05/26/2022 03:06 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:MARGARETS FAMILY HOMEFACILITY NUMBER:
486800471
ADMINISTRATOR:MROZ, MARGARETFACILITY TYPE:
735
ADDRESS:566 FIESTA CT.TELEPHONE:
(707) 421-0714
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 2DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Margaret Mroz, Administrator & LicenseeTIME COMPLETED:
03:17 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Margaret Mroz, Administrator & Licensee. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.
LPA conducted a walk-through of the facility and all exits were observed unobstructed. Facility has a screening station with sign-in sheet and COVID-19 questionnaire. Administrator screened LPA for symptoms and took LPA's temperature upon arrival. Administrator has a current CPR/first aid certification. Fire extinguisher was charged and serviced 03/01/2022.
The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, COVID-19 test kits, and surgical masks. Staff have received training on the following topics: infection prevention, symptoms, transmission and PPE use. Staff and client's temperatures are taken daily and documented. Administrator cleans and disinfects the facility on a daily basis. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing. Licensee has submitted the facility's Infection Control Plan, which is pending review. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. LPA discussed the following requirements with Licensee: Obtain N-95 mask fit testing for staff (Cal/OSHA requirement).
LPA requested the following updated records to be submitted to Community Care Licensing by 06/16/2022:
· LIC 308 Designation of Facility Responsibility; · LIC 500 Personnel Report; · LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash); · LIC 402 Surety Bond; · LIC 610D Emergency Disaster Plan; · LIC 9020 Register of Facility Clients; · Copy of current Administrator's Certificate; · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

Exit interview conducted with Licensee/Administrator Margaret Mroz, whose signature on this document confirms receipt. *No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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