<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800768
Report Date: 06/21/2022
Date Signed: 06/21/2022 04:07:16 PM

Document Has Been Signed on 06/21/2022 04:07 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:PENNSYLVANIA CARE HOMEFACILITY NUMBER:
486800768
ADMINISTRATOR:PUNZALAN, ELPIDIOFACILITY TYPE:
735
ADDRESS:2055 PENNSYLVANIA AVENUETELEPHONE:
(707) 438-0267
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Virginia Punzalan, Co-AdministratorTIME COMPLETED:
04:17 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Virginia Punzalan, Co-Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. LPA conducted a tour of the facility with staff; exits were unobstructed. The facility has a screening station (hand sanitizer, a thermometer, COVID questionnaire, and a sign-in sheet for visitors and staff). LPA was screened for COVID-19 symptoms and temperature was taken and documented. The facility has a designated visitation area, provides virtual visits and phone calls for visitors to stay in contact with clients. Client's temperatures are taken twice daily and documented. LPA observed COVID-19 precaution postings, hand soap/sanitizer and paper towels available in bathrooms. The facility has a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and gowns. LPA verified staff's vaccination status for COVID-19 during this visit. Staff CPR/1st aid certifications in file.
LPA discussed the following requirement with co-Administrator:
· Facility to obtain N-95 mask fit testing for staff (Cal/OSHA requirement)

LPA requested the following updated forms to be submitted to Community Care Licensing by 07/11/2022:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· LIC 402 Surety Bond
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current Administrator's Certificate
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
Exit interview conducted with Administrator, 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: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3