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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801782
Report Date: 03/24/2022
Date Signed: 03/24/2022 11:33:00 AM

Document Has Been Signed on 03/24/2022 11:33 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:CO-OPFACILITY NUMBER:
486801782
ADMINISTRATOR:YOLANDA LEEFACILITY TYPE:
775
ADDRESS:320 CERNON STREETTELEPHONE:
(707) 449-9377
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 45CENSUS: 15DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Staff, Marcela EduardoTIME COMPLETED:
11:37 AM
NARRATIVE
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Licensing Program Analyst (LPA) Walters arrived unannounced to conduct a Required 1- Year infection control visit, and was greeted by staff. The Administrator was not present during todays visit. This visit will focus on the infection control of this facility. The facility submitted a mitigation plan which was approved by Community Care Licensing on 06/03/2021.

When LPA arrived at the facility, staff checked LPA's temperature and signed LPA in using a sign in sheet. LPA is advising that the facility include screening questions into their sign in policy to monitor for COVID symptoms. Signs were posted at the entrance to inform visitors that a mask must be worn while inside the facility. All staff were wearing face mask. Bathrooms were supplied with hand washing supplies and paper products. Facility has a limited amount of Personal Protective Equipment. LPA is advising that the facility maintains at least a 30 day supply. Clients were sectioned off into separate activity rooms and engaged in activities. After LPA arrived, clients were taken to a community outing. Toxins were kept inaccessible to clients in care. The fire extinguisher was last serviced on 10/21/22. LPA observed that there were no carbon monoxide detectors in the facility. Administrator confirmed this by phone. Facility has hardwired alarms which are tested yearly. LPA learned that the current Administrator is Samika Simmons and that the Licensee has not yet reported the Change of Administrator to Community Care Licensing. LPA is requesting that the facility submits the following forms to Community Care Licensing by 3/25/22, attention LPA Walters: LIC 215, LIC500, LIC308, LIC501 and statement from board of resolution. A technical assistance citation was issued today for not reporting change of Administrator, as required by regulation 85061(b), and for not maintaining a 30 day supply of PPE. Exit interview conducted with staff.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. This report was read and discussed with Esther Penaflor Appeal rights were provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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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Document Has Been Signed on 03/24/2022 11:33 AM - It Cannot Be Edited


Created By: Katrina Walters On 03/24/2022 at 11:11 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CO-OP
FACILITY NUMBER: 486801782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
1503.2 Carbon monoxide detectors required. Every facility licensed shall have one or more carbon monoxide detectors in the facility.. department shall account for the detectors during inspections. This requirement was not met as evidenced by:

Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed there wasn't a carbon monoxide detector in the facility. This was confirmed by staff and phone call to Administrator, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2022
Plan of Correction
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Administrator agrees to purchase a carbon monoxide detector for use in the facility. To clear this violation, Administrator to certify on LIC 9098, that a detector was purchased and state where the detectors was placed in the facility. Certification to be submitted to CCL by 3/28/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022


LIC809 (FAS) - (06/04)
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