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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803243
Report Date: 03/29/2022
Date Signed: 03/29/2022 05:18:46 PM

Document Has Been Signed on 03/29/2022 05:18 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:CAREBESTFACILITY NUMBER:
486803243
ADMINISTRATOR:ZHANG, GUOLIANFACILITY TYPE:
735
ADDRESS:2376 BURGUNDY WAYTELEPHONE:
(707) 427-8776
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Silva Rosario, House ManagerTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Silva Rosario, House Manager. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.

LPA conducted a walk-through of the facility with live-in staff Lim & Yanfei. LPA observed COVID-19 precaution postings. The facility has designated visitation areas for visitors. Staff and Client temperatures are taken once a day. LPA observed 3 clients in care. The facility has 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 which was reviewed by the California Department of Social Services, Community Care Licensing.

LPA discussed the following requirements related to COVID-19 precautions with Silva Rosario, House Manager:
    · Staff to ensure COVID-19 screening questionnaire, sign-in sheet, hand sanitation, and temperature check is being completed for all visitors.
    · Verifying COVID-19 vaccination or COVID-19 test for indoor visitation
    · N-95 respirator Fit testing (Cal/OSHA requirement) for staff. Administrator to obtain documentation for completion for CCL verification.
    · Staff & visitors to wear face masks indoors regardless of vaccination status
    · Staff training in the following topics: infection prevention, symptoms, transmission and PPE use.
Report continued on LIC809-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CAREBEST
FACILITY NUMBER: 486803243
VISIT DATE: 03/29/2022
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LPA observed the following items needing repair (photos taken):
    · Kitchen floor observed lifting.
    · Bathroom (in master bedroom) 1 of 3 floor in need or repair.



LPA requested Licensee to submit the following documents to change the administrator:
LIC215, LIC500, LIC308, LIC501, & Administrator Certificate


The facility received a citation for the deficiency observed above.
Appeal rights given. California Code of Regulations, (Title 22, Division 6), are being cited on the attached LIC 809-D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/29/2022 05:18 PM - It Cannot Be Edited


Created By: Karina Canela On 03/29/2022 at 04:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CAREBEST
FACILITY NUMBER: 486803243

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This Requirement was not met as evidenced by: Based on observations and statements, Licensee did not ensure the regulation above due to kitchen floor observed lifted and bathroom 1 floor observed needing repair. This is a potential health and personal rights risk to clients in care.
POC Due Date: 05/02/2022
Plan of Correction
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Licensee to submit pictures as proof of corrected items to Community Care Licensing attention LPA Karina Canela by POC due date 05/02/2022 to clear the citation. If more time is needed, Licensee shall request it from LPA prior to the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022


LIC809 (FAS) - (06/04)
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