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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801782
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:11:36 PM

Document Has Been Signed on 02/23/2023 03:11 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:CO-OPFACILITY NUMBER:
486801782
ADMINISTRATOR:SIMMONS, SAMIKAFACILITY TYPE:
775
ADDRESS:320 CERNON STREETTELEPHONE:
(707) 449-9377
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 45CENSUS: 15DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Marcela Eduardo, Floor Supervisor (on-site) and
Samika Simmons, Administrator (via phone)		TIME COMPLETED:
03:30 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) Jill Nakagawa arrived unannounced to conduct a required 1- Year infection control visit, and was greeted by staff. The Administrator was contacted via phone. 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 and an Infection Control Plan on 08/08/2022.

When LPA arrived at the facility, staff checked LPA's temperature and signed LPA in using a sign in sheet. It was observed that the two (2) staff members present were wearing masks. Five (5) clients were on site at the time. Signs were posted at the entrance to inform visitors that a mask must be worn while inside the facility. Bathrooms were supplied with hand washing supplies and paper products. Facility has a limited amount of Personal Protective Equipment. There were two main activity rooms and an independent working area and staff office. LPA arrived at the end of the daily session; residents were prepared for transportation to take them home. Toxins were kept inaccessible to clients in care in a storage closet in one of the bathrooms. The fire extinguishers were last serviced on 10/17/22, and all three (3) were fully charged. LPA observed one (1) carbon monoxide detector in the facility, which was operational. Facility has hardwired alarms which are tested yearly. The facility was a comfortable temperature of 71 F. Clients provide their own lunches daily; staff help them in heating anything up with an available stove or microwave. Clients' medications are kept on site in a locked cabinet and dispersed as required via doctor's orders.

The facility was decorated for the Valentine's Holiday with a variety of heart projects made by the clients.

There were no deficiencies found at the time of inspection. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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 1