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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801821
Report Date: 06/17/2021
Date Signed: 06/21/2021 06:09:39 PM

Document Has Been Signed on 06/21/2021 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ANN'S CARE HOMEFACILITY NUMBER:
486801821
ADMINISTRATOR:BEST, DEBRA ANNFACILITY TYPE:
740
ADDRESS:124 DELTA CIRCLETELEPHONE:
(707) 643-3363
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 5CENSUS: 1DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Debra Ann Best, LicenseeTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Licensee Debra Ann Best (DAB). The facility currently provides care for 1 resident with a diagnosis of dementia.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 9/28/2020 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the facility bathroom and garage. LPA observed a gardening sheer located in the backyard accessible to resident, which was immediately removed. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings.

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at the front door, and facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Staff and residents are screened for temperature and symptoms on a daily basis and recorded. Staff conduct routine COVID testing that falls in line with mitigation plan.

No deficiencies cited during today's visit. Appeal Rights Given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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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