486801299-8-24-2021-21-AS-SHAN-C67P7J-20210824110403

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801299
Report Date: 08/24/2021
Date Signed: 08/24/2021 11:04:13 AM

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:	LUISA'S BOARD AND CARE		FACILITY NUMBER:	486801299
ADMINISTRATOR:	DATUIN, LUISA OCA		FACILITY TYPE:	740
ADDRESS:	201 GREENMONT DRIVE		TELEPHONE:	(707) 648-9297
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 4	DATE:	08/24/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Administrator Luisa Datuin & Caregiver Delia Delrosario		TIME COMPLETED:	11:05 AM

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	At 9:10 AM on 8/24/2021 Licensing Program Analyst Hansen arrived unannounced to conduct a required Annual 1 yr. Infection Control inspection and met with Caregiver Delia Delrosario. Luisa Datuin, Licensee/Administrator arrived later and continued inspection with LPA. Facility has 4 residents at this time. LPA arrived at the facility and had temperature checked and logged into visitor’s binder. The facility was a comfortable temperature, free from obstructions. and was well lit. Extra hygiene products and linens were available and required bath mats and grab bars were observed. Water temperature in resident's bathrooms measured 106.1 degrees F and 107.2 degrees F which are within acceptable range of 105 to 120 degrees F. Cleaning products and other toxins are located in the locked garage. Knives are located in a locked cabinet in the kitchen. Medications were centrally stored and locked with facility files in living room cabinet. Fire extinguisher located in the kitchen was last inspected 7/01/2021. Smoke detectors located throughout the facility and carbon monoxide detector were tested and functional. Annual Fire Inspection was held on 7/13/2021. Exit doors have auditory alert system. Perishable and non-perishable foods were sufficient. Administrator told LPA last disaster/fire drill was March of 2021 and are usually practiced every 3 months. Staff, Delia Del Rosario has required 1st Aid and CPR certificates, with expiration date of 6/10/2023. Staff Roberto Abendan also has required 1^st Aid and CPR certificates, with expiration date of 7/09/2023. Continue LIC 809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

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: LUISA'S BOARD AND CARE	FACILITY NUMBER: 486801299
	VISIT DATE: 08/24/2021

NARRATIVE

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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 staff office. Facility has hired staff since COVID-19 who were tested in advance. 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.

LPA Hansen reviewed Licensing Information System (LIS) with staff who stated that is corrected and updated at this time. 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 which is not being used but instead Residents have been using Facetime and telephone calls for visits. Residents have also available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing.

LPA issued a Technical Assistance to associate S1 to facility

LPA Hansen is requesting Licensee to update and submit the following documents by 9/07/2021:

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

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC809 (FAS) - (06/04)

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