486803302-9-1-2022-21-AS-DTOA-CHUT65-20220901142633

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803302
Report Date: 09/01/2022
Date Signed: 09/01/2022 02:26:43 PM

Document Has Been Signed on 09/01/2022 02:26 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:	WILLIAMS BOARD & CARE HOME		FACILITY NUMBER:	486803302
ADMINISTRATOR:	WILLIAMS, KATRINA		FACILITY TYPE:	735
ADDRESS:	430 FORDHAM DRIVE		TELEPHONE:	(707) 652-2445
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY: 6		CENSUS: 6	DATE:	09/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Margaret Henley, House Manager		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by House Manager, Margaret Henley. LPA contacted Administrator, Katrina Williams and notified them of the visit. The facility currently provides care for six (6) clients, all of which were present at the time of visit. LPA arrived at the facility and had temperature and symptoms checked. LPA continued with a tour of the facility with House Manager; 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 2/16/2022 at the time of the visit. Smoke and Carbon Monoxide detectors were inspected and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are to be stored in a designated secured cabinet located in the hallway. Upon inspection, LPA observed two containers of powdered bleach cleaning supply located in the restroom accessible to clients. Item was immediately removed by House Manager and placed in secure location. There was an ample supply of hygiene products and paper products available for client use. All client’s bedrooms have lighting & appropriate furnishings. Hot water measured at 105.1 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by clients. LPA conducted a review of staff training records and found staff to have current CPR & 1st Aid Certification. Continued onto LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

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: WILLIAMS BOARD & CARE HOME	FACILITY NUMBER: 486803302
	VISIT DATE: 09/01/2022

NARRATIVE

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Infection Control:
Facility to submit Infection Control Plan which will be reviewed. All staff and clients have been vaccinated with no reported or observed symptoms. Posters will be placed at the front door, and facility will re-implement a station at main entrance with a sign in, hand sanitizer and other items designated for visitors and staff. Staff are screened for temperature and symptoms on a daily basis and clients are screened observation and change of condition.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

LPA requested the following documents be sent to CCL by COB 9/15/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/01/2022 02:26 PM - It Cannot Be Edited

Created By: Dominic Tobola On 09/01/2022 at 02:09 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: WILLIAMS BOARD & CARE HOME	FACILITY NUMBER: 486803302
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 2 powder bleach cleaning supplies located under the client restroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2022
	Plan of Correction
1 2 3 4	Powder bleach cleaning supplies were immediately removed and secured. Deficiency cleared at the time of visit. Licensee agrees to secure all toxins and cleaning supplies that could pose as a potential health & safety risk to clients.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Kimberley Mota

LICENSING EVALUATOR NAME:

Dominic Tobola

LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC809 (FAS) - (06/04)

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