<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801556
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:46:12 PM

Document Has Been Signed on 05/12/2022 12:46 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:ALL SEASONS CARE HOMEFACILITY NUMBER:
486801556
ADMINISTRATOR:GARCIA, PERLA V.FACILITY TYPE:
735
ADDRESS:993 BUTTERNUT CT.TELEPHONE:
(707) 416-3862
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Susana Quisquino, live-in staffTIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with lead/live-in staff Susana Quisquino. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.
Facility has a screening station with sign-in sheet ,thermometer, COVID questionnaire, and hand sanitizer. LPA was screened for symptoms upon arrival and asked to sign in and complete COVID questionnaire. LPA conducted a walk-through of the facility with Staff. Clients were at Day Program during inspection.
The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff and client's temperatures are taken daily and LPA verified documentation. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. Staff stated they clean and disinfect the facility throughout the day. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing.

Staff have completed training on Proper utilization of PPE, Infection Prevention & Control (IPC), and Environmental Cleaning & Disinfection to prevent COVID-19 and other Infection/Communicable Diseases. Staff received training certificate of completion from Solano County Public Health on 4/29/2022.
Designated staff have successfully completed N-95 Fit Testing (Cal OSHA requirement); LPA verified documentation. During this inspection, LPA verified staff's proof of COVID-19 vaccination. LPA verified P & I records, which were accurate and not commingled.

LPA discussed the following requirements with staff Susana
· COVID-19 vaccination requirements for staff specified in Provider Information Notice (PIN) 22-05.1-ASC (deadline for booster shots was 03/01/2022; weekly testing required for staff who have not completed the requirement).
· Document verification of COVID-19 vaccination or proof of negative test for all indoor visitations.
Report continued on LIC809-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ALL SEASONS CARE HOME
FACILITY NUMBER: 486801556
VISIT DATE: 05/12/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA requested the following updated records to be submitted to Community Care Licensing by 05/30/2022
    · LIC 308 Designation of Facility Responsibility (1 person per form)
    · LIC 500 Personnel Report
    · LIC 400 Affidavit Regarding Client/Resident Cash Resources
    · LIC 402 Surety Bond
    · LIC 610D Emergency Disaster Plan
    · LIC 9020 Register of Facility Clients
    · Copy of current Administrator's Certificate
    · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

    · Updated facility sketch (form LIC 999) and indicate which bedrooms are designated for client use and which are staff use.

    Currently there are 2 bedrooms occupied by staff (one near kitchen and the other is the main/master bedroom). There are 2 private bedrooms and 1 shared bedroom (with 2 clients C1 & C2) occupied by clients.


Exit interview conducted with Staff Susana, whose signature on this document confirms receipt.

No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2