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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801323
Report Date: 07/29/2021
Date Signed: 07/29/2021 10:46:54 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:JT EVERGREEN CARE HOMEFACILITY NUMBER:
486801323
ADMINISTRATOR:COPERO, JOHNNYFACILITY TYPE:
740
ADDRESS:115 MICHAEL CRT.TELEPHONE:
(707) 557-0180
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Licensee/Administrator, Johnny CoperoTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct an Annual inspection at approximately 9:40 AM, and met with administrator Johnny Copero. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPA was screened for COVID symptoms and asked to sign in by staff. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with administrator and observed COVID postings throughout. Mitigation plan was received and reviewed by LPA during visit.

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Staff have completed Personal Protective Equipment (PPE) and infection control training through local public health. High touch surface areas are disinfected daily. There are empty rooms available to isolate residents if they became ill. LPA confirmed licensee has necessary PPE equipment and supplies to support a resident in isolation.

Residents' emergency contact information has been updated and licensee confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked garage cabinets. A 30 day supply of medications are stored in a locked cabinet, making them inaccessible to residents. The facility has a sufficient supply of PPE located in hallway closet. Exit alarms on exit doors were working properly. Facility is conducting COVID-19 surveillance testing per CCL guidelines. LPA provided guidance to ensure a copy of mitigation plan is available for review on request at the facility. LPA requested updated client roster and liability insurance during visit.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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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