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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803119
Report Date: 07/26/2021
Date Signed: 07/26/2021 04:33:00 PM

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:C & C RESIDENTIAL CARE HOME INC.FACILITY NUMBER:
486803119
ADMINISTRATOR:CORSIGA, ALMAFACILITY TYPE:
740
ADDRESS:2018 BLUEBIRD WAYTELEPHONE:
(707) 344-2628
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 4DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Alma Corsiga, AdministratorTIME COMPLETED:
04:41 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Alma Corsiga, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA and Administrator discussed implementing a screening station at front entrance to include hand sanitizer, a COVID-19 questionnaire, and the sign-in sheet for staff and visitors. LPA and Administrator discussed documenting COVID-19 questionnaires for staff/visitors and for staff to screen all (including essential) visitors when entering the facility.
LPA conducted a walk-through of the facility with Administrator and observed COVID-19 precaution postings. Staff's temperatures are taken and documented upon arrival to the facility. Client's temperatures are taken and documented twice per day. Administrator stated staff clean the facility 3 times per day and disinfect high touched surface areas 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, one client is currently in a rehabilitation facility recovering from a hip surgery. Facility staff have completed training on PPE use, isolation policies, and infection prevention (Administrator to document). N-95 respirator Fit testing (Cal/OSHA requirement) is in process. LPA observed a supply of PPE including gloves, face shields, 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 to be reviewed by the California Department of Social Services.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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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