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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803302
Report Date: 08/26/2021
Date Signed: 08/26/2021 03:43:01 PM

Document Has Been Signed on 08/26/2021 03:43 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:WILLIAMS BOARD & CARE HOMEFACILITY NUMBER:
486803302
ADMINISTRATOR:WILLIAMS, KATRINAFACILITY TYPE:
735
ADDRESS:430 FORDHAM DRIVETELEPHONE:
(707) 731-2326
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 6DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Administrator Katrina Williams & Manager Margaret HenleyTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was met by Staff Margaret Henley who contacted Administrator Katrina Williams and arrived at facility later. Five of six clients were present at the facility as the final client was at on the job training with his case manager.

At 1:25 pm LPA arrived at the facility and had her temperature checked and logged. All staff are temperature checked and logged each shift and wear masks. During facility tour on 8/26/2021 with staff Margaret Henley, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 08/23/2019 at the time of the visit. Smoke Detectors & Carbon Monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked closet in hallway closet. Medications are stored locked and inaccessible to clients in a locked standalone cabinet in the dinning room that also contains client’s files. There was a supply of cleaners, hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Hot water temperature measured between 119.5 degrees F which is within acceptable regulations of 105 to 120 degrees F in client’s bathroom faucets.

Administrator & Staff’s 1st Aid and CPR certificates are at another facility locked up and will send copies of current certificates to LPA Dominic Tobola by end of month (Tuesday 8/31/2021) to prevent a citation.

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small stand with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in hallway closet & garage. Facility has a 30-day supply of medication for clients. Clients are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit.

Continued LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: WILLIAMS BOARD & CARE HOME
FACILITY NUMBER: 486803302
VISIT DATE: 08/26/2021
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In addition, facility has a designated area for visitors. Clients are able to use the “client” house phone for facetime and telephone calls when contacting family members and others, as well many of the clients have their own phones. Staff had PPE training required but still need to get N-95 fit testing. Disaster Drills have been conducted quarterly with the last one being conducted on 7/2021.

LPA reviewed Licensing Information System (LIS) with administrator who stated that is correct and updated at this time other than the phone number needs to be changed to (707) 652-2445. In addition, LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

There were no deficiencies found in the areas inspected.

LPA is requesting the following documents to be submitted to CCL in order to update facility file by 09/10/2021:

Copy of 1st Aid and CPR Certificates

LIC 308 Designated

LIC 500 Personnel Summary

LIC 400 Affidavit Regarding Resident Cash Resources

LIC 402 Surety Bond

LIC 610 Emergency Disaster Plan

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Current Administrator's qualifications and Certificate

Copy of Deed and/or Lease of Property

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC809 (FAS) - (06/04)
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