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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802064
Report Date: 07/12/2021
Date Signed: 07/12/2021 03:57:58 PM

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:COMFORT LIVING FOR SENIORS IIFACILITY NUMBER:
486802064
ADMINISTRATOR:SADDI, DONABELL W.FACILITY TYPE:
740
ADDRESS:685 PURPLE MARTIN DRIVETELEPHONE:
(707) 410-9706
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 6DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Donabell SaddiTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Walters conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was greeted by staff. Administrator, Donnabell Saddi (DS) arrived later. LPA conducted a Risk Assessment with Administrator prior to entry. At the time of inspection there were two staff providing care and supervision for six residents. five residents were socially distanced in the living room.

Upon arrival, staff checked LPAs temperature and logged it in binder LPA was not screened for COVID symptoms. LPA advised that DS includes screening questions to facility sign-in sheet. Hand sanitizer and disposable mask were available at entrance.

LPA/DS conducted a tour through the facility and observed facility was a comfortable temperature and passageways were free from obstructions. Proper signage was posted though out the facility to promote socially distancing and hand washing. Resident rooms were furnished per regulation. Bathrooms were stocked with paper towels and hand washing supplies. LPA was able to verify that facility maintains a 30 day supply of medication for residents. Medications were centrally stored in a locked medication room. Facility has a 30-day supply of PPE located in the hallway closet.

The facility has designated indoor and outdoor spaces for visitation. Staff have not yet been fit-tested for N-95 mask. LPA provided Administrator with PIN 21-10. Per Administrator, residents are screened for COVID-19 symptoms each shift. LPA advised that the facility documents this. The Administrator will conduct an infection control training for COVID-19 and send a copy to CCL by Friday, 7/16/21. Facility is disinfected throughout the day.

Continued on 809 C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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: COMFORT LIVING FOR SENIORS II
FACILITY NUMBER: 486802064
VISIT DATE: 07/12/2021
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Continued from 809

A mitigation plan has been submitted for this facility. LPA/DS reviewed the facility mitigation plan and approved it on 7/12/21. LPA is also requesting a copy of the following documents: Copy of Liability Insurance, LIC 308 Designation of Responsibility, LIC 500 Personnel Roster by 7/14/21. Certificate for Administrator, Donabell Saddi 601542740, expires on 6/21/22.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC809 (FAS) - (06/04)
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