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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801479
Report Date: 04/15/2022
Date Signed: 04/15/2022 12:17:11 PM

Document Has Been Signed on 04/15/2022 12:17 PM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:EXCEL CAREFACILITY NUMBER:
486801479
ADMINISTRATOR:MANIO, JESUS & ESPERANZAFACILITY TYPE:
740
ADDRESS:1728 SERENO DRIVETELEPHONE:
(707) 644-6799
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
04/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Jesus Manio, LicenseeTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by Staff Simon Vinluan. Licensee, Jesus Manio (JM) was contacted and arrived during the visit. The facility currently provides care for five (5) residents some of which with a diagnosis of dementia.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Licensee and facility staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 3/1/2022 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are securely stored under kitchen and linen closet. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Hot water measured at 111.5 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by residents. In addition, all staff have updated CPR & 1st Aid training on file. LPA observed auditory alarm to be in disrepair in 1 of 5 resident bedrooms. Licensee agrees to replace alarm and provide proof of corrections to LPA.

Infection Control:
Facility Licensee and LPA completed COVID Mitigation Program Plan during the visit and has been approved. All staff and residents have been vaccinated with no reported or observed symptoms. Posters have been placed at the front door, and facility has a station at main entrance with a sign in, hand sanitizer and other items designated for visitors and staff. Staff are screened for temperature and symptoms on a daily basis and residents are screened on a daily basis.

Exit interview conducted with facility Licensee, whose signature on this document confirms receipt.
A copy of the signed report was emailed to Licensee.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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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