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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802010
Report Date: 07/07/2021
Date Signed: 07/07/2021 10:30:12 AM

Document Has Been Signed on 07/07/2021 10:30 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:GOOD SAMARITAN CARE HOMEFACILITY NUMBER:
486802010
ADMINISTRATOR:GARCIA, BRENDAFACILITY TYPE:
740
ADDRESS:3113 PEBBLE BEACH CIRCLETELEPHONE:
(707) 718-0498
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 6CENSUS: 5DATE:
07/07/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator, Brenda GarciaTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Farhaan Sarangi arrived at Good Samaritan Care Home for the purpose of conducting an unannounced Annual/Random inspection. LPA met with Administrator, Brenda Garcia and was granted access into the facility.

LPA toured the facility and found the facility was at comfortable temperature, and was well lit. Hygiene products and linens were available and required bath mats and grab bars were observed. Water temperature in resident's bathrooms measured at an acceptable range of 105 to 120 degrees F. Cleaning products and other toxins are located in a locked cabinet in the laundry room. 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 Responsible Parties handle their own cash resources. Fire extinguisher located in the kitchen was last inspected October 2020. Smoke detectors located throughout the facility and carbon monoxide detector were tested and functional. Exit doors have auditory alert system. The last Disaster Drill was conducted on April 17, 2021. Administrator Certificate for Brenda Garcia, #6002773740 expires on March 24, 2022.

In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

No deficiencies were observed or cited during this Annual/Random inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Brenda Garcia.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2021
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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