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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800557
Report Date: 03/10/2022
Date Signed: 03/10/2022 11:20:29 AM

Document Has Been Signed on 03/10/2022 11:20 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:I.M.P.A.C.TFACILITY NUMBER:
486800557
ADMINISTRATOR:JOETTA GRIFFINFACILITY TYPE:
775
ADDRESS:2573 CLAY BANK ROAD, SUITE 12TELEPHONE:
(707) 862-2105
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 90CENSUS: DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Administrator, Gabby EchevarriaTIME COMPLETED:
11:30 AM
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At approximately 10:00AM, Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced to conduct an Annual inspection visit and was greeted by Administrator, Gabby Echevarria. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival at the facility, LPAs had their temperatures checked and logged. LPAs conducted a walk-through of the facility and observed the following: some COVID-19 signs were observed at the entry way and some throughout the facility. Per conversation with Administrator, there is a client that likes collecting the COVID-19 signs. Hand-washing signs were missing in some bathrooms. Administrator agreed to put COVID-19 and handwashing signs back up. Observed staff were wearing masks. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

All staff have received training on infection control and proper donning and doffing of Personal Protective Equipment (PPE). Facility has a cleaning and disinfecting schedule that occurs three times per day. Bathrooms are disinfected immediately after use. Facility has at least a 30-day supply of PPE for clients. Staff and Clients are screened daily for COVID-19 symptoms and it is logged into facility binders.

Fire Extinguishers are due to be updated this month. Per conversation with Administrator, the Fire Department is scheduled to inspect fire extinguishers and smoke systems on March 18, 2022. Administrator provided text message conversation confirming this appointment.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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