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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801831
Report Date: 08/19/2022
Date Signed: 08/22/2022 11:39:12 AM


Document Has Been Signed on 08/22/2022 11:39 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: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: 6DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Evelyn BayonTIME COMPLETED:
05:11 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator/Licensee, Evelyn Bayon. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. There are currently 5 residents in care. This facility is licensed for 6 non ambulatory residents, with hospice waiver approved for 2 of the residents and none of the residents are approved for bedridden.

LPA toured facility and grounds and observed COVID-19 precaution signs posted in common. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Facility follows indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels and required hand washing postings. Covid-19 Mitigation plan was reviewed by Community Care Licensing department on 1/4/2022. Caregivers have completed PPE training but have not been N-95 Fit tested.

In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguisher was found to be charged and serviced May 16, 2022.

Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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: BENICIA ANGEL'S HOME 1, INC.
FACILITY NUMBER: 486801831
VISIT DATE: 08/19/2022
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LPA went over reporting requirements for incident reports to be submitted to CCL within 7 days. Report any Covid positive cases of staff and residents immediately to CCL. Went over Provider Information Notice (PIN) 21-40-ASC. LPA reminded facility to continue following Covid precautions. Masks must be worn at all times by staff in the facility and any staff not fully vaccinated must be tested weekly for Covid-19.


LPA requested the following updated records to be submitted to Community Care Licensing (CCL) 9/19/2022.

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610 Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Copy of administrator certificate
Copy of liability insurance
Copy of current Lease/Rental Agreement



Exit interview conducted with Evelyn Bayon.
No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
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