486801931-9-9-2021-21-AS-KWAS-C6PPGH-20210909111822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801931
Report Date: 09/09/2021
Date Signed: 09/09/2021 11:19:24 AM

Document Has Been Signed on 09/09/2021 11:19 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	DUNGARVIN CALIFORNIA LLC		FACILITY NUMBER:	486801931
ADMINISTRATOR:	NOWLIN, JERAMIE		FACILITY TYPE:	775
ADDRESS:	310 E MONTE VISTA AVE STE A		TELEPHONE:	(707) 449-3722
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95688
CAPACITY: 45		CENSUS:	DATE:	09/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Jeramie Nowlin, Administrator		TIME COMPLETED:	11:35 AM

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 Analysts (LPA) Walters arrived unannounced to conduct an 1- Yr Required inspection and met with Program Director, Jeramie Nowlin (JN). The inspection is focused on the Infection Control procedures and practices of this facility. This facility has submitted a mitigation plan that was reviewed and approved by Community Care Licensing on 03/01/21. When LPA arrived at the facility, they were greeted by staff, who checked their temperature and signed LPA in. At the entry of the facility there were sign in sheets for both staff and visitors with screening questions, hand sanitizer and additional disposable mask. There were three clients and three staff present during todays visit. The day program operates four days a week, broken -up into two sessions each day. The facility is closed one day during the week for a scheduled deep cleaning. Client's have temperature checked and are screened before they arrive to the facility. All screenings are recorded on residents daily log. LPA began tour with JN at approximately 10:00 AM and made the following observations: Continued on 809 C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: DUNGARVIN CALIFORNIA LLC	FACILITY NUMBER: 486801931
	VISIT DATE: 09/09/2021

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Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in facility hallway closet. There were sufficient amounts of cleaning supplies, incontinence products and emergency food. A 30+ day supply of personal protective equipment (PPE) are in cabinets in each client activity room. Automatic hand sanitizer dispensers were located at every threshold. Signs were posted throughout the facility to promote hand washing and social distancing. Signs are placed on the floor to direct the flow of traffic. Per JN the facility is disinfected twice daily and in between activities. Staff deep clean the facility once a week. Bins are located in each activity room, for staff to disinfect activities after their usage.

The facility has an isolation room for individual who may began to show symptoms. The room is equipped to hold two individuals, and has an exit to minimize exposure. A donning and doffing cart is set up outside of the isolation room. All staff have completed infection control training as proven by facility meeting notes. Facility has developed a plan for identifying staff and clients who have been vaccinated and which vaccination they have received.

No citations issued.

Exit interview conducted with the Program Director, Jeramie Nowlin.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

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