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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801831
Report Date: 08/03/2021
Date Signed: 08/03/2021 02:40:17 PM

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:BENICIA ANGEL'S HOME 1, INC.FACILITY NUMBER:
486801831
ADMINISTRATOR:BAYON, EVELYNFACILITY TYPE:
740
ADDRESS:458 MILLS DRIVETELEPHONE:
(707) 748-0482
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY:6CENSUS: 5DATE:
08/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Caregiver, Zaneida AlveTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Benicia Angel's Home 1, Inc. for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Caregiver, Zaneida Alve. Administrator, Evelyn Bayon arrived at 01:58 PM.

LPA toured the facility with Caregiver, Zaneida Alve. The facility was a comfortable temperature of 75 degrees, free from obstructions, and was well lit. Extra hygiene products and linens were available and required bath mats and grab bars were observed. Water temperature in resident's bathrooms measured at 128.3 degrees F which is not an acceptable range of 105 to 120 degrees F (See LIC 9102-Technical Violation). Water temperature was corrected on site by Administrator. Water temperature is now at 110 degrees. Cleaning products and other toxins are located in the locked garage and locked under sink cabinet. Knives are located in a locked drawer in the kitchen. Perishable and non-perishable foods were sufficient, with a 2 day supply of perishable foods, and a 7 day supply of non-perishable foods, as required. Medications were centrally stored and locked. Residents handle their own cash resources. Fire extinguisher located in the kitchen was last inspected July 2021. Smoke detectors located throughout the facility and carbon monoxide detectors were tested and functional. Exit doors have auditory alert system.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the storage room. Staff have had all PPE training required and will be in the process of obtaining N95 Fit testing for employees.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Evelyn Bayon.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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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