486802010-5-1-2023-21-AS-FSAI-CRESE5-20230501134810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486802010
Report Date: 05/01/2023
Date Signed: 05/01/2023 01:48:27 PM

Document Has Been Signed on 05/01/2023 01:48 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 HOME		FACILITY NUMBER:	486802010
ADMINISTRATOR:	GARCIA, BRENDA		FACILITY TYPE:	740
ADDRESS:	3113 PEBBLE BEACH CIRCLE		TELEPHONE:	(707) 718-0498
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	6	CENSUS: 3	DATE:	05/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Licensee, Brenda Garcia		TIME COMPLETED:	02:00 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), Farhaan Sarangi arrived unannounced at Good Samaritan Care Home for the purpose of conducting a Required 1 year inspection. Upon arrival, LPA was greeted at the door by Caregiver, Jotiann Zulita, and was granted access into the facility. Licensee arrived 15 minutes later. LPA and Licensee toured the facility. LPA found the facility to be clean and at a comfortable temperature with all exits free from obstruction. Hygiene products and linens were available and required bath mats and grab bars were observed. Water temperature in resident's bathrooms measured at 105 degrees in 2 out of 2 bathrooms and is within an acceptable range of 105 to 120 degrees F. Fire Extinguisher was last charged on October 2022. First Aid Kit was inspected and found to be appropriate during the inspection. 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 during the inspection. 3 out of 3 Medication logs for residents in placement were reviewed and found to be appropriate during the inspection. Smoke detectors located throughout the facility and carbon monoxide detector were tested and were operational during the inspection. Exit doors have auditory alert system. Food menu was presently available for viewing during the inspection. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all resident bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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: GOOD SAMARITAN CARE HOME	FACILITY NUMBER: 486802010
	VISIT DATE: 05/01/2023

NARRATIVE

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LPA and Licensee reviewed the Infection Control Plan for the facility. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. In addition, LPA and Licensee reviewed the Emergency Disaster Plan. Last Emergency Disaster Drill conducted was February 2023.

File reviews were conducted. 3 of 3 resident files were reviewed. However, during the Required 1 year inspection, LPA observed 1 out of 3 resident records did not have a Reappraisal in resident file. LPA educated the Licensee on the importance of this regulation (See LIC 9102-Technical Advisory). LPA conducted resident interviews during this Required 1 year inspection. 2 of 2 staff files were reviewed. However, during the review LPA found that the Licensee did not retain her training inside her folder (See LIC 9102-Technical Advisory). LPA educated the Licensee on the importance of this regulation. LPA interviewed staff members during the Required 1 year inspection.

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Most up-to-date Liability insurance
Control of Property
Register of residents
Copy of Administrators Certificate

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the Licensee.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC809 (FAS) - (06/04)

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