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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803027
Report Date: 05/30/2023
Date Signed: 05/30/2023 12:30:55 PM

Document Has Been Signed on 05/30/2023 12:30 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:ONE STEP AT A TIME CARE HOMEFACILITY NUMBER:
486803027
ADMINISTRATOR:VILLALOBOS-SANTOS, MARIAFACILITY TYPE:
735
ADDRESS:503 MARINA BLVDTELEPHONE:
(707) 427-8553
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 6CENSUS: 4DATE:
05/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Maria Villalobos-SantosTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Required - 1 Year inspection. LPA was granted access into the facility by Fabricio Santos, Licensee. Administrator Maria Villalobos-Santos arrived later.
LPA toured the facility and observed all exits were unobstructed. The facility was found to be at a comfortable temperature.
Fire extinguisher was charged and serviced 04/26/2023. 4 smoke detectors and 1 carbon monoxide detector were tested and observed operational. LPA observed a supply of linens (bedding, towels, etc.), and disinfectants/cleaning solutions (observed locked). Client bedrooms were furnished per regulation. Facility food supply was within regulation. Medication was centrally stored and locked. LPA reviewed staff and client records. Staff have current training certifications in First Aid & Cardiopulmonary Resuscitation (CPR) in file. P&I cash resources for client (C3) was locked and not commingled in an individual bank account. LPA discussed Health & Safety Code 1565(c) and Title 22, Division 6 Regulations 80068.2(b)(1) and 80069(c)(4).

LPA requested the following updated forms to be submitted to Community Care Licensing by 06/30/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Surety Bond
· LIC 610D Emergency Disaster Plan
· Copy of current Administrator's Certificate
· LIC9020 Register of facility client/residents


Exit interview conducted with Administrator, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2023
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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