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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800791
Report Date: 10/25/2022
Date Signed: 10/25/2022 12:07:33 PM

Document Has Been Signed on 10/25/2022 12:07 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:ZINA'S CARE HOME IIFACILITY NUMBER:
486800791
ADMINISTRATOR:ZINA LEEFACILITY TYPE:
735
ADDRESS:2112 ALLSTON PLACETELEPHONE:
(707) 432-1312
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Zina LeeTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Zina's Care Home I for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Staff Member #1, Tamara Carlson and was granted access into the facility. Administrator arrived 20 minutes later.

LPA toured the facility with the Administrator, Zina Lee. LPA found the facility to be clean and at a comfortable temperature with all exits free from obstruction. LPA observed all walkways and exits to be unobstructed. There were no fire arms, weapons, or bodies of water on the premises during the inspection. The amount of fresh and non-perishable foods was within regulation. Hot water temperature was tested and found to be at 108 degrees, within Title 22 regulation of 105-120 degrees. Toxins are secured in a lock cabinet located in the laundry room and not accessible to clients. The fire extinguisher was charged/serviced back in February 2022. Smoke detectors and 1 carbon monoxide detector was tested and observed to be operational during the inspection. Facility's last Fire/Disaster Drill was conducted September 10, 2022. Client records, personnel Records, medication, toxins are all kept locked and inaccessible to the clients in care. Medication records are centrally stored, and observed locked in a cabinet located near kitchen. Facility has a first aid kit which was found to be appropriate during the inspection. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings, and client’s beds were outfitted with mattress pads as required by Title 22 Regulations.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA reviewed the Mitigation Plan with the facility. Facility will contact Solano County Public Health regarding N95 Fit testing. (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ZINA'S CARE HOME II
FACILITY NUMBER: 486800791
VISIT DATE: 10/25/2022
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LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator due to printer issues.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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