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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801381
Report Date: 07/29/2021
Date Signed: 07/29/2021 12:05:22 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:ALMABELLA MANORFACILITY NUMBER:
486801381
ADMINISTRATOR:GUBA, ALMABELLAFACILITY TYPE:
740
ADDRESS:3323 TENNESSEE ST.TELEPHONE:
(707) 645-7389
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee/Administrator Almabella GubaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct an Annual inspection at approximately 11:00 AM, and met with licensee/administrator Almabella Guba. The inspection is focused on the Infection Control procedures and practices of this facility.

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

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. Staff have been N95 fit tested through local public health. High touch surface areas are disinfected daily. Plan is in place 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 under locked kitchen sink. A 30 day supply of medications are stored in a locked cabinet, making them inaccessible to residents. The facility has a sufficient supply of Personal Protective Equipment (PPE) and hygiene supplies located in storage area. Facility has 100 percent vaccination rate for staff/residents and has therefore discontinued surveillance testing per CCL guidelines.

Continued on LIC 809 C
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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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: ALMABELLA MANOR
FACILITY NUMBER: 486801381
VISIT DATE: 07/29/2021
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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Visits are occurring both inside the facility as well as on the outdoor patio area.

LPA requested the following documents during visit:

LIC 500
LIC 308
LIC 610E
LIC 9020
Liability Insurance

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
LIC809 (FAS) - (06/04)
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