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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803285
Report Date: 09/18/2023
Date Signed: 09/18/2023 06:28:12 PM


Document Has Been Signed on 09/18/2023 06:28 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 & F SENIOR CARE HOMEFACILITY NUMBER:
486803285
ADMINISTRATOR:FOJAS, LINAFACILITY TYPE:
740
ADDRESS:1120 SONGWOOD ROADTELEPHONE:
(707) 246-0867
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
09/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Lina FojasTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator, Lina Fojas. There are currently 5 residents in care. This facility is licensed for 6 non ambulatory residents, with hospice waiver approved for 3 of the residents and none of the residents are approved for bedridden.

LPA toured the home and found the home organized at a comfortable temperature with all exits free from obstruction. This home is a two level home and all the resident bedrooms are located on the first level of the home. Residents have a call button to alert staff and call bell button was tested and operational during inspection. Exit doors have auditory alarms to alert staff. Smoke detectors and carbon monoxide detectors were tested and operational. The fire extinguisher located in the kitchen was observed charged and facility had a proof of purchase receipt attached of 6/19/2023. Fire drill was conducted by the facility and documented on 9/3/2023. Water temperature in the resident bathroom was tested and found to be within appropriate range of 105-120 degrees. Bathrooms have required non-skid surfaces and grab bars. Cleaning products and knives are stored in locked cabinets in the kitchen.

There was a 7 day supply of non-perishable foods. There are adequate dishes, glasses and silverware. Residents' medications are stored in kitchen locked cabinet and closet. Resident and staff files are located and locked in closet. LPA reviewed staff files and staff have the required training and proof of CPR/1st aid that expires 2025. Resident files were reviewed and found complete and organized. LPA reviewed medication.


Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023
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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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: C & F SENIOR CARE HOME
FACILITY NUMBER: 486803285
VISIT DATE: 09/18/2023
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LPA discussed Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit the current following documents by 10/15/2023:


· LIC 308 Designation of Facility Responsibility (Received 9/18/2023)
· LIC 500 Personnel Report- (Received 9/18/2023)
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan (Received 9/18/2023)
· LIC 9020 Register of Facility Residents (Received 9/18/2023)
Infection Control Plan of Operation (If changes)
Copy of Liability Insurance- (Received 9/18/2023)
Copy of Administrator Certificate (Received 9/18/2023)



No citations issued during todays inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC809 (FAS) - (06/04)
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