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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803074
Report Date: 08/24/2021
Date Signed: 08/24/2021 01:24:13 PM

Document Has Been Signed on 08/24/2021 01:24 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:BUENAVISTA HOME AT EAGLE RIDGEFACILITY NUMBER:
486803074
ADMINISTRATOR:RONALDO S. PEREZFACILITY TYPE:
735
ADDRESS:6135 WILD DUNE COURTTELEPHONE:
(707) 561-0388
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Ronald Perez &Caregiver Nimpa BaldedaraTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met by Staff Nimpa Baldedara who contacted Administrator Ronaldo Perez and arrived at facility shortly after. One of the 4 clients was present at the facility as the other three are back to attending day programs in person. Facility has outings for clients to parks, and other activities during the day.

LPAs arrived at the facility and had her temperature checked and logged. All staff are temperature checked and logged each shift and wear masks. During facility tour on 8/24/2021 with Administrator Ronaldo Perez, 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 06/25/2021 at the time of the visit. Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked closet in the laundry room. Medications are stored locked and inaccessible to clients cabinet in kitchen cabinet right above the locked cabinet containing staff & clients files. There was a supply of cleaners, hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Hot water temperature measured between 111.3 degrees F & 111.5 degrees F which is within acceptable regulations of 105 to 120 degrees F in client’s bathroom faucets.
Staff, Nimpa Baldedara has required 1st Aid and CPR certificates, with expiration date of 01/2022.

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small nook with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in kitchen, laundry room & garage. Facility has a 30-day supply of medication for clients. Clients are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Administrator stated all staff & clients have been fully vaccinated.

Continued LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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: BUENAVISTA HOME AT EAGLE RIDGE
FACILITY NUMBER: 486803074
VISIT DATE: 08/24/2021
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In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Clients have also available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had PPE training required on file and have had N-95 fit testing.

LPA reviewed Licensing Information System (LIS) with administrator who stated that is correct and updated at this time. In addition, LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted monthly with the last one being conducted on 7/29/2021.

There were no deficiencies found in the areas inspected.

LPA is requesting the following documents to be submitted to CCL in order to update facility file by 09/07/2021:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 400 Affidavit Regarding Resident Cash Resources

LIC 402 Surety Bond

LIC 610 Emergency Disaster Plan

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Current Administrator's qualifications and Certificate

Copy of Deed and/or Lease of Property

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC809 (FAS) - (06/04)
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