486802064-8-17-2023-21-AS-DTOA-CUSVTG-20230817164304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486802064
Report Date: 08/17/2023
Date Signed: 08/17/2023 04:43:11 PM

Document Has Been Signed on 08/17/2023 04:43 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 II		FACILITY NUMBER:	486802064
ADMINISTRATOR:	SADDI, DONABELL W.		FACILITY TYPE:	740
ADDRESS:	685 PURPLE MARTIN DRIVE		TELEPHONE:	(707) 410-9706
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	6	CENSUS: 5	DATE:	08/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Donabell Saddi, Administrator		TIME COMPLETED:	05:00 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	On 8/17/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Lead Caregiver Staff, Mildred Mamaraldo. Administrator, Donabell Saddi was contacted and arrived later in the visit. The facility is single story building licensed for 6 non-ambulatory and 2 bedridden residents, along with a hospice waiver capacity of 2. The facility currently provides care for 5 residents, 1 of which is receiving hospice services and some residents with a diagnosis of dementia. LPA continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 5/5/2023. Both smoke detectors and carbon monoxide detectors throughout the facility were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins stored under the kitchen sink, pantry and garage were found to be properly secured as per regulations on this day at the time of the visit. There was a supply of hygiene products and paper products available for residents. All resident bedrooms have lighting & appropriate furnishings. Water was measured at faucets accessible to residents and measured between 116.2 and 118.0 degrees F which is within regulation. Medications located in hallway were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Facility has transitioned to utilizing Centrally Stored Medication Records on an electronic computer drive. Resident were observed interacting with staff in the common area, listening to music or resting in their bedrooms for leisure. There is one emergency exit located in the backyard which was found to be unobstructed. All auditory alarms leading out of the facility send chime to the kitchen and living room area and were all in working order. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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: COMFORT LIVING FOR SENIORS II	FACILITY NUMBER: 486802064
	VISIT DATE: 08/17/2023

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LPA conducted a sample file review for staff and found all staff to have annual staff training on file. One staff (C1) had recently started working in the facility as of July 2023 and requires 16 additional hands-on
training required to meet the 40 hours of initial staff training. Technical Advisory issued. LPA also conducted a file review for all residents. Upon review, LPA found that all resident (R1, R2, R3, R4 & R5) require an updated Needs & Service Plan completed. Last appraisals were conducted in July 2022. Technical Violation issued.

Licensee, Donabell Saddi's Administrator Certification 6015452740 is valid through 4/28/2024.

LPA requested the following documents be sent to CCL by COB 9/17/2022:

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

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC809 (FAS) - (06/04)

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