486803077-4-20-2023-21-AS-JNAA-CR3QY5-20230420123434

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803077
Report Date: 04/20/2023
Date Signed: 04/20/2023 12:34:42 PM

Document Has Been Signed on 04/20/2023 12:34 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:	VICTORPAZ FARMHOUSE		FACILITY NUMBER:	486803077
ADMINISTRATOR:	GOMEZ, ANNALEE		FACILITY TYPE:	740
ADDRESS:	506 KINGS WAY		TELEPHONE:	(707) 439-3757
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 5	DATE:	04/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Annalee Gomez, Administrator		TIME COMPLETED:	12:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Required 1-Year Annual Inspection and met with Administrator, Annalee Gomez. This facility submitted a mitigation plan, which was approved by community care licensing on 02/26/21, as well as the Infection Control Plan

When LPA arrived at the facility they were greeted by 2 carestaff. There were 5 residents in care. At the entrance, there was a sign in sheet with a symptom check list and hand sanitizer. LPA toured the facility with staff and found the facility to be clean and comfortable and providing a cheery, homey atmosphere. Signs were posted appropriately informing the use of oxygen. Bathrooms were equipped with grab bars and non-skid rugs. Paper towels and antibacterial soap were also available in bathrooms used by residents and staff. All residents' rooms were furnished per regulation. Facility is able to isolate resident in an isolation room in the event of an outbreak. Medications are securely stored in a locked medication cart and each resident has a 30-day supply of medications. Facility is disinfected daily. Cleaning products were not accessible to residents in care.

Kitchen was clean and orderly and there were perishable and non-perishable food stores as required per Title 22. Sharps were locked and inaccessible to residents. The living room had reclining chairs for the comfort of each resident while watching television, listening to music or partaking in activities together. The backyard includes a lovely covered patio for residents to enjoy the warm weather under shelter from the sun.

Staff and resident records were complete and within regulation. Fire clearance is for three (3) non-ambulatory and three (3) bedbound. There were 3 fire extinguishers, last charged and inspected on June 16, 2022; fully charged. There were two (2) carbon monoxide detectors, which were tested and operational. There were seven (7) smoke detectors, which were tested and operational.

There were no deficiencies found at the time of inspection. No citations cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

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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