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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803119
Report Date: 07/11/2022
Date Signed: 07/11/2022 12:18:09 PM


Document Has Been Signed on 07/11/2022 12:18 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: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:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alma Corsiga, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual 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 conducted a tour of the facility which with Administrator; all exits were observed unobstructed. The facility has a screening station (hand sanitizer, a thermometer, COVID questionnaire, and a sign-in sheet for visitors and staff). The facility has a designated visitation area, provides virtual visits and phone calls for visitors to stay in contact. Client's temperatures are taken twice daily and documented. LPA observed COVID-19 precaution postings. The facility has a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and gowns. The facility has submitted their Infection Control Plan to be reviewed by the California Department of Social Services, Community Care Licensing. LPA verified staff's vaccination status for COVID-19 during this visit. Refresher training's on PPE donning/doffing, Infection Prevention & Control, and Environmental Cleaning to Prevent COVID-19 and other Infectious Diseases conducted with Solano County Public Health was completed on 02/23/2022 with staff.
LPA discussed the following requirements with Administrator:
· Facility to obtain N-95 mask fit testing for staff (Cal/OSHA requirement)
· Wear face mask regardless of vaccination status
· Paper towels to be available in the bathrooms

LPA requested the following updated forms to be submitted to Community Care Licensing by 07/25/2022:
· 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); · LIC 402 Surety Bond; · LIC 610E Emergency Disaster Plan; · LIC 9020 Register of Facility Residents; · Copy of current Administrator's Certificate
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
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: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
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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