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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801542
Report Date: 01/07/2022
Date Signed: 01/07/2022 02:28:48 PM

Document Has Been Signed on 01/07/2022 02:28 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LEISURE HOMEFACILITY NUMBER:
486801542
ADMINISTRATOR:SLAY, BRENDAFACILITY TYPE:
735
ADDRESS:931 READING WAYTELEPHONE:
(707) 451-4905
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 3DATE:
01/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Brenda SlayTIME COMPLETED:
02:37 PM
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On 1/7/2020, Licensing Program Analyst (LPA) Walters arrived unannounced to conduct an Annual/Required 1 Year inspection and was greeted by Brenda Slay, Administrator. There are currently 3 clients in care at the time of the inspection. This inspection is focused on infection control.

LPA began a tour and inspection of the building and grounds which was found to be clean and a comfortable temperature. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secured in a cabinet in the locked garage and not accessible to clients. There is a sufficient supply of hygiene products and linens on hand for client use. Restrooms were stocked with liquid soap and paper towel. Facility has a 30-day supply of Personal Protective Equipment (PPE), Incontinence products and medication. Medication was centrally stored and locked in the kitchen. Signs were posted throughout the facility to promote physical distancing and droplet precaution.

LPA and Administrator discussed: the facility creating a sign-in sheet and monitoring clients daily for temperature changes and symptoms; Updating visitor policy; and PIN-21-53 regarding Vaccination And Booster Requirements. LPA requested Facility to update the following documents: Emergency Disaster Plan. LPA also requested the following documents to be sent to the Regional Office, LIC 309, LIC 308, LIC 500 and updated liability insurance.

There no deficiencies cited during today's visit. Exit interview conducted.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2022
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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