486801831-8-30-2023-21-AS-ACAA-CV83N5-20230830182322

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801831
Report Date: 08/30/2023
Date Signed: 08/30/2023 06:24:17 PM

Document Has Been Signed on 08/30/2023 06:24 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:	BENICIA ANGEL'S HOME 1, INC.		FACILITY NUMBER:	486801831
ADMINISTRATOR:	BAYON, EVELYN		FACILITY TYPE:	740
ADDRESS:	458 MILLS DRIVE		TELEPHONE:	(707) 748-0482
CITY:	BENICIA	STATE: CA	ZIP CODE:	94510
CAPACITY:	6	CENSUS: 4	DATE:	08/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Evelyn Bayon		TIME COMPLETED:	04:31 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) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator/Licensee, Evelyn Bayon. There are currently 4 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 initiated a tour of the facility and made the following observations: Facility was clean, organized and at a comfortable temperature, with passageways free from obstructions. Residents rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 110 degrees F which is within the required range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinet containing cleaning supplies was observed locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility maintains emergency food and water supplies. Fire extinguishers were fully charged and last serviced March 18, 2023. Smoke and Carbon Monoxide detectors located throughout the facility were operational. Most recent disaster drill was conducted June 2023. Administrator Certificate for Evelyn Bayon, #6018780740 expires on 10/5/2024. Staff have First Aid and CPR certificates. LPA reviewed 4 resident files that contained all records. Three staff files were reviewed and had the required training and employee records. Medication records were reviewed and in order. Required postings were observed. Continued Report see LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

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: 08/30/2023

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LPA consulted regarding information needed to be submitted if the facility wants to request a locked perimeter.

Licensee/Administrator to submit updates of the following documents by 9/28/2023:

LIC 500 Personnel Summary-
LIC308 Designation of Facility Responsibility
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)
Copy of Liability Insurance
Copy of Administrators Certificate

No Citations issued during todays inspection

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

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