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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801443
Report Date: 11/15/2021
Date Signed: 11/15/2021 06:08:09 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:MASONIC GUEST HOMEFACILITY NUMBER:
486801443
ADMINISTRATOR:LACAP, LEONIDAFACILITY TYPE:
740
ADDRESS:310 MASONIC DR.TELEPHONE:
(707) 554-1432
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
11/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Leonida LacapTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with staff, Lucy Pineda and Administrator, Leonida Lacap who arrived a few minutes later. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

LPA toured facility and grounds with Administrator 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. Infection control practices are present: entry procedures, face covering, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Facility to follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test within 72 hours. Staff clean and disinfect the facility twice daily or more if needed. Bathrooms are equipped with liquid soap and paper towels. Staff understand hand sanitizer should not be placed in the rooms of residents who lack hazard awareness and impulse control. Facility submitted a mitigation program plan, and plan has been reviewed. Caregivers have completed PPE training but have not been N-95 Fit tested.

In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. No accessible bodies of water or fire safety hazards observed. Fire Extinguisher was found to be charged and serviced 8/2021. Smoke and Carbon monoxide detectors were fully operational. There was sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations.

LPA requested the following updated documents to be submitted to CCLD by 11/19/2021:
· LIC500 Personnel Report
· LIC9020 Register of Residents
Exit interview conducted with Administrator, due to printer malfunction, this report will be emailed to Administrator.
No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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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