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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802066
Report Date: 07/19/2022
Date Signed: 07/19/2022 02:12:34 PM


Document Has Been Signed on 07/19/2022 02:12 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:CLARIN'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
486802066
ADMINISTRATOR:CLARIN, JULIANAFACILITY TYPE:
740
ADDRESS:3024 CLEAR COAST COURTTELEPHONE:
(707) 557-6837
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 4DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Licensee/Administrator, Juliana MelegritoTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and was greeted by a caregiver. Licensee/Administrator arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed posters outside notifying visitors that mask must be worn in the facility. LPA was greeted by staff but was not screened. LPA filled out the visitor form and attempted to take own temperature but thermometer was not functioning properly. Thermometer was a a temporal thermometer so must touch the forehead. LPA did not observe wipes to disinfect the thermometer after use. Once Licensee arrived, LPA confirmed that facility is not conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA instructed Licensee to review PINs regarding visitation and vaccination verification. LPA initiated a walk-through of the facility at around 12:40pm and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility maintains documentation of staff and resident daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff have not completed PPE training and have not been N95 fit tested. LPA and Licensee discussed visitation.

Facility does not have a 30 day supply of Personal Protective Equipment (PPE) and will need to obtain N-95s, gowns and face shields in case a resident or residents need to be isolated. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced July 2021. Smoke and carbon monoxide detectors throughout facility were tested and operational.


Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: CLARIN'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 486802066
VISIT DATE: 07/19/2022
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Continued from LIC809

Licensee and LPA discussed their Emergency Disaster Plan and infection control plan.

Licensee/Administrator to submit updates of the following documents by 8/19/2022:
LIC 308 Designated Administrator
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If changes)
LIC 9020 Register of Facility Client’s/Resident’s
Copy of current Administrator's Certificate
Copy of Liability Insurance

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2