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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801750
Report Date: 05/26/2022
Date Signed: 05/26/2022 06:09:30 PM

Document Has Been Signed on 05/26/2022 06:09 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:MIRACLE LANE HOUSEFACILITY NUMBER:
486801750
ADMINISTRATOR:PUNZALAN, ELPIDIOFACILITY TYPE:
735
ADDRESS:1625 FAIRFIELD AVE.TELEPHONE:
(707) 422-2906
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Marissa Gueco, House ManagerTIME COMPLETED:
06:20 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Marissa Gueco, House Manager. Administrator Ed Punzalan arrived later and met with LPA. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.

LPA conducted a walk-through of the facility and all exits were observed unobstructed. Facility has a screening station with sign-in sheet, COVID-19 questionnaire and thermometer. House manager took LPA's temperature upon arrival and screened for COVID symptoms. Staff have current CPR/first aid certifications. Fire extinguisher was charged and serviced 05/05/2022.
The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff have received training on the following topics: infection prevention, symptoms, transmission and PPE use. Staff and client's temperatures are taken daily and documented. Staff clean and disinfects the facility on a daily basis. LPA observed COVID-19 precaution postings and liquid hand soap available in the bathrooms.
LPA verified staff vaccination records during this inspection.
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.

Report continued on LIC 809-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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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: MIRACLE LANE HOUSE
FACILITY NUMBER: 486801750
VISIT DATE: 05/26/2022
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LPA discussed the following requirements with Marissa Gueco, House Manager:
    · Facility to obtain N-95 mask fit testing (not training) for staff (Cal/OSHA requirement).
    · Facility to send proof of front fence and ramp railing is repaired (which was recently hit by a car)
    · Paper towels required to be available in bathrooms.
    · Staff to keep Client's ointments locked and inaccessible to clients
    · Prior to construction or alterations, notify Community Care Licensing (CCL) of the proposed change.
    (new construction of a sun room was observed; CCL was not notified prior to construction as required)


LPA requested the following updated documents to be submitted to Community Care Licensing by 06/16/2022:
· LIC 308 Designation of Facility Responsibility
· 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.
· Facility to submit copies of building permits for the new construction of the sun room

Exit interview conducted with Marissa Gueco, House Manager, 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: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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