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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802064
Report Date: 07/20/2022
Date Signed: 07/20/2022 02:40:56 PM

Document Has Been Signed on 07/20/2022 02:40 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: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:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Donabell Saddi (Licensee)TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection to this facility and met with Licensee, Donabell Saddi.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility have a poster on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/Licensee conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene and paper products. Commonly touched surfaces are disinfected at least three times a day. Each resident has their own room except one room that it is been shared by two residents, but facility has the option to take one of the residents to a sister facility in case that needs to isolate and the facility is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and N-95 fit tested. Staff and residents are being monitored daily and results are documented. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate and received boosters for staff and residents. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. Residents receive indoor visitation with their families and facility is able to perform antigen tests to visitors as well as screening, documenting for symptoms and tracking purposes. Facility has submitted their Covid Mitigation Plan and approved on 7/12/21. Per Licensee, the facility has not submitted their Infection Control Plan to CCL for review and LPA provided a copy of LIC9282 form to Licensee who was acknowledge and agreed to fill out and submit as soon as possible to be in compliance with CCL regulations. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are accessible for staff.

Licensee will provide updates of the following by 7/29/22: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Liability insurance and Emergency Disaster Plan (LIC610E).
No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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