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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800791
Report Date: 11/28/2023
Date Signed: 11/30/2023 03:48:57 PM

Document Has Been Signed on 11/30/2023 03:48 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: 3DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Tamara Clarkson, DSPTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA)Jill Nakagawa arrived at Zina's Care Home II for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by House Manager Mary Foster-Brown (MF) and was granted access into the facility. Administrator Zina Lee arrived later. There are 3 residents in care.

LPA toured the facility with staff member Tamara Clarkson. 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 105 degrees, within Title 22 regulation of 105-120 degrees. Toxins are secured in a locked cabinet located in the laundry room and not accessible to residents. The 4 fire extinguishers were charged/serviced on 10/02/2023. 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, 2023. Resident records, personnel Records, medication, toxins are all kept locked and inaccessible to the residents in care. Medication records are centrally stored, and observed locked in a cabinet located near kitchen. Facility has a first aid kit. Dangerous items were stored in a locked drawer in kitchen inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available.
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SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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: 11/28/2023
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Continued....

All residents'' bedrooms have lighting and appropriate furnishings, and residents' beds were outfitted with mattress pads as required by Title 22 Regulations.

LPA requested the following documents to be sent:

Infection Control Plan
LIC 500- Personnel Report
LIC 309- Administrative Organization
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 provided for Administrator/Licensee.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
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