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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803243
Report Date: 08/22/2022
Date Signed: 08/22/2022 11:42:00 AM

Document Has Been Signed on 08/22/2022 11:42 AM - 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:
08/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Silva Rosario, House ManagerTIME COMPLETED:
11:52 AM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to clear deficiencies cited during an Annual Required - 1 Year inspection on 03/29/2022. LPA met with Silva Rosario, House Manager. Licensee had sent in pictures as proof of cleared deficiencies prior to the due date, LPA arrived today to verify the following deficiencies were corrected:
    · Kitchen floor observed lifting.
    · Bathroom (in master bedroom) floor in need or repair.

LPA observed items were corrected. Additionally during inspection, LPA observed 2 individuals (I1 & I2) who were not associated on the guardian roster to the facility as required. LPA verified with the Santa Rosa Regional office that the 2 individuals were fingerprint cleared and the Licensee had sent paperwork for the individuals to be associated but there was an error in the facility name. LPA requested the forms LIC 508, LIC 9182, and copies of the individual's photo IDs to be submitted to the Santa Rosa Regional Office to associate the individuals.
Licensee/Administrator Mark Zhang stated he understood and will send the required paperwork today 08/22/2022 to associate staff

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 negative 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.
No deficiencies cited during today's inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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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