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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803079
Report Date: 08/19/2021
Date Signed: 08/19/2021 03:15:58 PM

Document Has Been Signed on 08/19/2021 03:15 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:RED JADE HOMEFACILITY NUMBER:
486803079
ADMINISTRATOR:PUNZALAN, ELPIDO A.FACILITY TYPE:
735
ADDRESS:913 JEFFERSON STREETTELEPHONE:
(707) 425-8165
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 3CENSUS: 3DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Virginia Punzalan, Co-AdministratorTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required inspection and met with Virginia Punzalan Co-Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Care Facility.

LPA conducted a walk-through of the facility with staff and observed COVID-19 precaution postings. A screening station was observed at front entrance of facility which had hand sanitizer, a thermometer, and a sign-in sheet for visitors and staff. Visitors and staff are screened for COVID-19 symptoms (including temperature check) prior to arrival to the facility. Unannounced visitors are also screened upon arrival to the facility. Client's temperatures are taken twice a day and LPA observed documentation. Staff clean and disinfect the facility three times daily. High touched surface areas are disinfected frequently and after use. The facility has a designated visitation area, provides virtual visits and phone calls for family to stay in contact with clients.
LPA observed 3 clients in care. Staff have completed training on infection prevention, symptoms, transmission and PPE use. N-95 respirator Fit testing (Cal/OSHA requirement) is in process. The facility has a supply of PPE including gloves, face shields/goggles, N-95 respirators, surgical masks and disposable gowns.
The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services.

Exit interview conducted with Co-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: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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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