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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801479
Report Date: 02/17/2023
Date Signed: 02/17/2023 10:28:17 AM


Document Has Been Signed on 02/17/2023 10:28 AM - 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: DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Jesus Manio, LicenseeTIME COMPLETED:
10:45 AM
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On 2/17/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Licensee, Jesus Manio. The facility currently provides care for 5 residents all of which were present at the time of visit. One residents is receiving hospice services and some of which with a of diagnosis of dementia.

LPA continued with a tour of the facility with Licensee. Facility was 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. Smoke and carbon monoxide detectors were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food stored properly. Residents are provided various alternative food options per meal with the facility ensuring well balanced and nutritious foods. Residents were observed to be walking around the facility common areas or in their respective bedrooms resting or watching television. All resident bedrooms have appropriate lighting and furniture with a supply of extra blankets and linens.

There was a supply of hygiene products and paper products available for resident use. LPA conducted a sample review of staff training and found that all staff have current CPR and 1st Aid training on file. Toxins are stored in a locked in facility garage and found to be secured. A pool was located in the backyard and found to have appropriate fencing secured locks. Additional sheds also located in the backyard were found to be secured.

Continued onto LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: EXCEL CARE
FACILITY NUMBER: 486801479
VISIT DATE: 02/17/2023
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Infection Control:
Facility has submitted an infection control plan for review. Posters have been placed at the front door, and facility has a station near facility entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. There is a sufficient amount of PPE supplies available. All staff and visitors were observed to have appropriate face coverings and following facility COVID protocols. Residents and staff are also screened for symptoms on observation.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 3/3/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC809 (FAS) - (06/04)
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