486800888-12-29-2021-21-AS-DTOA-CA6RZ4-20211229122719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486800888
Report Date: 12/29/2021
Date Signed: 12/29/2021 12:28:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	MED RESIDENTIAL CARE HOME II		FACILITY NUMBER:	486800888
ADMINISTRATOR:	VERANO, MATILDA		FACILITY TYPE:	740
ADDRESS:	1243 GRANADA ST.		TELEPHONE:	(707) 552-8550
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY:	6	CENSUS: 5	DATE:	12/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	House Manager, Mercedita Manalo		TIME COMPLETED:	12:25 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) Tobola arrived unannounced to conduct a Required - 1 Year inspection and met with House Manager, Mercedita Manalo (MM) and Lead Staff Hermie Manadapat (HM). Licensee, Matilda Verano (MV) was contacted and notified of the visit. The annual inspection is focused on the Infection Control procedures and practices of this facility. There are 5 residents in care, 3 of which are on hospice and some of which with a diagnosis of dementia. LPA toured facility and grounds with House Manager and observed COVID-19 precaution signs posted in common areas to promote hand washing and physical distancing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Staff follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test within 72 hours. Staff clean and disinfect the facility daily. House Manager stated high touched surface areas are disinfected after each use, such as the bathroom and kitchen area. resident rooms and common areas have disinfecting wipes and hand sanitizer. Bathrooms are equipped with liquid soap, paper towels and garbage cans with touch less lids. Facility submitted a mitigation program plan, and plan has been reviewed. Caregivers have completed PPE training for COVID mitigation. In addition, all staff have current 1st Aid & CPR Training on file. Toxins and cleaning supplies are all located in a secured cabinet located in the garage. The garage is also locked from the inside with access only to staff. There is a shed located in the backyard that stores multiple mattresses which will be removed as per Lead Staff. Lead Staff also stated that residents that are bedridden are on a two hour schedule for repositioning to prevent sores and wounds. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MED RESIDENTIAL CARE HOME II	FACILITY NUMBER: 486800888
	VISIT DATE: 12/29/2021

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Facility was found to be at a comfortable temperature with all exits free from obstruction. No accessible bodies of water or fire safety hazards observed. Fire Extinguishers were found to be charged and serviced 12/1/2020. Licensee had contacted the Vallejo Fire Department for fire extinguisher inspection services but was postponed to January 2022. Licensee agrees to submit proof of updated fire extinguisher inspection to CCL. Smoke and Carbon monoxide detectors were tested and found to be in working order. Water temperature for faucets accessible to residents were found to be within regulation. There was sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit.

LPA requested the following updated documents to be submitted to CCLD by 1/5/2022:

LIC500 Personnel Report
LIC308 Designation of Administrative Responsibility
LIC610 Emergency Disaster Plan

Exit interview conducted with House Manager and Lead Staff, whose signature on this document confirms receipt.
A copy of the signed report was emailed to Licensee.

No deficiencies cited during this inspection

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021

LIC809 (FAS) - (06/04)

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