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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801055
Report Date: 11/15/2022
Date Signed: 11/15/2022 02:05:15 PM

Document Has Been Signed on 11/15/2022 02:05 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:TWIN RESIDENTIAL CARE HOMEFACILITY NUMBER:
486801055
ADMINISTRATOR:ALMONIA, SONIA G.FACILITY TYPE:
735
ADDRESS:129 COLERIDGE DR.TELEPHONE:
(707) 644-1961
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Henry Almonia, House ManagerTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an annual Required-1 year inspection and met with Henry Almonia, House Manager. There were 2 carestaff at the facility at the time of inspection. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. There are currently five clients in care. At the time of inspection all 5 residents were participating in virtual lessons.

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 upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for clients and staff, and 30-day PPE supply. The facility was found to be clean and well-organized, and all exits were free from obstructions, as well as a comfortable temperature. Bathrooms are equipped with liquid soap and paper towels. Kitchen was stocked with ample non-perishable and perishable foods as required in Title 22. Sharps and medications were locked and inaccessible to residents. Toxins were stored and locked in garage, inaccessible to residents. Doors were equipped with operational door alarms.
Covid-19 Mitigation plan was submitted to the department on 3/2/2021, and the Infection Control Plan was submitted April 15, 2022. 2 Fire Extinguishers were found to be last charged and serviced on April 18, 2022.

LPA requested updated LIC 500 (Personnel Report), Resident Roster, and LIC 610D (Emergency Disaster Plan).

Exit interview conducted with Henry Almonia, House Manager and a copy of this report was given.
No deficiencies cited during today's inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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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