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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802010
Report Date: 05/03/2024
Date Signed: 05/03/2024 03:31:59 PM


Document Has Been Signed on 05/03/2024 03:31 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:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Brenda Garcia, AdministratorTIME COMPLETED:
03:45 PM
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On 5/3/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Administrator, Brenda Garcia. The facility currently provides care for 3 residents, none of which are receiving hospice services and some of which with a diagnosis of dementia.

LPA continued with a tour of the facility with Administrator, facility found to be clean and at a comfortable temperature with all exits free from obstruction and equipped with appropriate auditory devices. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was recently purchased on 11/10/2023 at the time of visit. Smoke and carbon monoxide detectors found throughout the facility, were tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings and labels. Staff provide residents with meals according to dietary plans with an ample amount of fresh and healthy foods observed.

Cleaning supplies and other toxins are safely stored in locked cabinets in the laundry room, garage all of which were secured upon inspection. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in a kitchen drawer. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Additional linens and toiletry items for resident use were also observed. LPA observed a small tear in the window screen of 1 out of 3 resident bedrooms. Tear is narrow with no signs of insects or other pests were observed. LPA requested for Licensee to repair and send corrections. Technical Violation issued.

Continued onto LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
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: 05/03/2024
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Residents that were awake during the inspection were observed interacting with staff in the common area, watching television or resting. LPA also observed staff providing mobility exercises with residents, catering to resident preferred activities and hosting resident/family visits. The facility encourages regular family visits and utilizes outdoor area with appropriate shading for resident use. There is one emergency exit located in the backyard which was found to be unobstructed.

A spot medication count was conducted with administering count and records to be in order. LPA conducted a sample file review for staff and found all staff to have appropriate annual training and 1st Aid & CPR certification on file. LPA conducted a review of all resident records and found items to be sufficient. All required positing and signeage at the front and hallway of the facility were found to be in order with information easily accessible for staff and residents.

Administrator, Brenda Garcia's Administrator Certification 6002773740 had expired March 2024 but currently pending for renewal. Administrator had recently submitted training requirements and application and is waiting to be placed on pending list. Administrator provided proof of application submitted March 4, 2024.

LPA requested the following documents be sent to CCL by COB 6/3/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Control of Property/Rental Agreement

No deficiencies cited.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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