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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801556
Report Date: 04/07/2023
Date Signed: 04/10/2023 10:39:35 AM

Document Has Been Signed on 04/10/2023 10:39 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: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:
04/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Susana Quisquino, house managerTIME COMPLETED:
05:16 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Susana Quisquino, house manager. Administrator was not available during time of inspection.

LPA toured the facility and observed all exits were unobstructed. Fire extinguisher was charged and serviced 10/14/2022. Carbon monoxide detector was tested and observed operational. LPA observed liquid hand soap and paper towels available in bathrooms. LPA reviewed staff and client records. Staff have completed cardiopulmonary resuscitation (CPR) training and first aid training. Food supply was within regulation. Client medication was centrally stored.


LPA requested the following updated forms to be submitted to Community Care Licensing by 05/08/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Surety Bond
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Clients
· Copy of current Administrator's Certificate

Exit interview conducted with house manager whose signature on this document confirms receipt. No deficiencies cited.

Report copy sent to Administrator by email.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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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