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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801556
Report Date: 05/03/2024
Date Signed: 05/03/2024 02:05:26 PM

Document Has Been Signed on 05/03/2024 02:05 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ALL SEASONS CARE HOMEFACILITY NUMBER:
486801556
ADMINISTRATOR/
DIRECTOR:		GARCIA, PERLA V.FACILITY TYPE:
735
ADDRESS:993 BUTTERNUT CT.TELEPHONE:
7074163862
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Susana Quisquino, House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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At approximately 8:40AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by House Manager, Susana Quisquino. Administrator, Perla V. Garcia was not present. House Manager contacted Administrator. LPA spoke with Administrator and was informed that she would not be able to be present for today's inspection due to a previously scheduled doctors appointment and CPR training. Administrator gave permission for House Manager to conduct the tour and sign for any paperwork. Facility is an Adult Residential Facility with Developmentally Disabled Clients in care. LPA was informed that all four clients were away at their day programs.

At approximately 8:50AM, LPA initiated a tour of the facility and observed the following: Facility was a comfortable temperature and passageways were free from obstructions. Water temperature in clients' bathrooms measured 116.4 and 117.6 degrees F, which is within allowable range of 105 to 120 degrees F per regulation. LPA observed a supply of clean linens available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. There is outdoor space for activities, and the facility plans weekly outings.

The facility is hardwired. Fire extinguisher was last serviced January 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular disaster drills bi-annually, and the most recent drill was conducted January 2024. LPA advised House Manager that drills shall be conducted quarterly moving forward. LPA observed the facility's infection control plan, first aid kit, and emergency disaster plan. LPA advised House Manager to update the facility emergency disaster plan to reflect an updated offsite location in the event of an evacuation. LPA observed changes to the floor plan and staff/resident room designations and was informed of renovations to the facility over the last few years. LPA issued a technical violation and informed House Manager that she needs to submit a new LIC200 with an updated facility sketch and processing fees to CCL to begin the change of capacity from 6 to 4 clients.
Continued on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ALL SEASONS CARE HOME
FACILITY NUMBER: 486801556
VISIT DATE: 05/03/2024
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Continued from LIC809

At approximately 9:30AM six staff files and four client files were reviewed. Staff have required First Aid certificates. LPA advised House Manager to send in healthscreening and TB results for newly hired staff member. LPA observed an exception on file for a three of four clients being over 59 years old. Medications are centrally stored and locked. LPA reviewed medications and medication records which are maintained appropriately per regulation. LPA reviewed P&I monies and logs, which were organized and maintained according to regulation.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 10 days of this visit:

LIC500- Personnel Report
LIC503 - Staff Health Screening
LIC200 - Application for Change of Capacity
LIC999 - Updated Facility Sketch

Exit interview conducted with house manager whose signature on this document confirms receipt. No Deficiencies were cited. This report was reviewed with House Manager.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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