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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801137
Report Date: 08/26/2021
Date Signed: 08/26/2021 11:39:41 AM

Document Has Been Signed on 08/26/2021 11:39 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ST. JOSEPH CARE HOME-BFACILITY NUMBER:
486801137
ADMINISTRATOR:HELEN RABAGOFACILITY TYPE:
740
ADDRESS:1405 DONNER PASS DRIVETELEPHONE:
(707) 333-1199
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 3DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator Helen RabagoTIME COMPLETED:
11:40 AM
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At 9:45 AM on 8/26/2021 Licensing Program Analyst Hansen arrived unannounced to conduct a required Annual 1 yr. Infection Control inspection and was met by Administrator Helen Rabago who took LPAs temperature and logged results in visitor’s binder. Facility has 3 residents at this time that has a capacity of 6.

The facility was a comfortable temperature, free from obstructions and was well lit. There was a sufficient amount of perishable and non-perishable foods in the kitchen and garage. Extra hygiene products and linens were available and required bathmats and grab bars were observed. Water temperature in resident's bathroom measured 119.8 degrees F which is within acceptable range of 105 to 120 degrees F. Cleaning products and other toxins are located in locked cabinet in the garage. Knives/sharps are kept in a locked cabinet in the kitchen. Medications were centrally stored and locked in a kitchen cabinet as well. Staff & Residents with facility files are kept in living room cabinet (office). Fire extinguisher located in the living room was last inspected 7/12/2021. Smoke detectors located throughout the facility and carbon monoxide detector were tested and functional. Annual Fire Inspection was held on 7/12/2021. Exit doors have auditory alert system.

Administrator told LPA last disaster/fire drill was in 2020 and are usually practiced quarterly but due to COVID they have been concerned about safety issues. Administrator informed LPA they would complete a drill soon and submit time to LPA Tobola along with copies of current 1st Aid and CPR certificates as she is unable to find but is certain they are current.

Infection Control:

Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in hallway closet & garage. Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility. All staff had masks on during this visit.

Continue LIC 809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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: ST. JOSEPH CARE HOME-B
FACILITY NUMBER: 486801137
VISIT DATE: 08/26/2021
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LPA Hansen reviewed Licensing Information System (LIS) with staff who stated that is correct except Landline needs to be changed to (707) 980-7833 and Mobile line is the (707) 333-1199. In addition, LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

In addition, facility has a designated area for visitors in the living room & backyard as well residents have been using Facetime and telephone calls for visits. Staff have not had PPE training required or been N-95 fit tested. TV has been given and LPA has discussed with Administrator the requirements and importance of these. Administrator will contact local public health to obtain information to complete PPE training & N-95 fit testing and also submit proof to LPA Tobola or CCL RPRO.


LPA Hansen is requesting Licensee to update and submit the following documents by 9/09/2021 to LPA or RPRO:

Proof of PPE training & N-95 Fit testing

Proof of Current Disaster/Fire Drill

Current 1st Aid & CPR Certificates

LIC 308 Designated

LIC 309 Administrative Organization

Articles of Corporation

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Administrator Certificate

Copy of Certificate of Liability Insurance

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC809 (FAS) - (06/04)
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