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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802010
Report Date: 05/13/2022
Date Signed: 05/13/2022 03:37:22 PM


Document Has Been Signed on 05/13/2022 03:37 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: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: 3DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Administrator, Brenda GarciaTIME COMPLETED:
03:48 PM
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At approximately 2:20PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct an Annual Inspection visit and was greeted by Administrator, Brenda Garcia. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival at the facility, LPA had their temperature checked and logged. LPA answered a standard COVID-symptom questionnaire. LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

Facility has a cleaning and disinfecting schedule that occurs twice per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for residents. Staff and Residents are screened daily for COVID-19 symptoms and it is logged into facility binders. Facility has a plan in place if a staffing shortage were to occur.

Fire extinguishers were last serviced October 2021. Carbon monoxide detectors were tested and operational. Per conversation with Administrator, fire alarms are checked every Monday. LPA reviewed fire alarm check log which stated that smoke and fire alarms detectors were last checked Monday, 5/9/2022.

Continued on LIC-809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
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: GOOD SAMARITAN CARE HOME
FACILITY NUMBER: 486802010
VISIT DATE: 05/13/2022
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Continued from LIC-809

LPA and Administrator discussed PIN 21-43-ASC regarding Mitigation Plans and PIN-22-13-ASC regarding Infection Control Plans.

LPA requested the following documents to be submitted to CCL by Close of Business, Wednesday, 5/18/2022:
  • Updated LIC 500 (Personnel Report)

No Deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
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