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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803243
Report Date: 03/20/2023
Date Signed: 03/20/2023 04:33:58 PM

Document Has Been Signed on 03/20/2023 04:33 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:
03/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Guolian (Mark) ZhangTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection. LPA was greeted by Rongmiu (Susan) Xu, DSP. Licensee and Administrator Guolian (Mark) Zhang arrived later.
LPA toured the facility and observed all exits were unobstructed. Fire extinguisher was charged and serviced 04/28/2022.
There are 6 smoke detectors & 1 carbon monoxide detector, which were tested & observed operational. LPA reviewed client and staff files. LPA observed medication to be centrally stored. Staff wore masks during this visit.
    LPA requested the following updated forms to be submitted to Community Care Licensing by 04/20/2023:
    · 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 9282 Infection Control Plan
    · Copy of Surety Bond
    · LIC 610D 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.
    · Copy of Client (C1)'s updated LIC 602

Exit interview conducted with Guolian (Mark) Zhang, Administrator, whose signature on this document confirms receipt. No deficiencies cited during today's visit.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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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