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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803334
Report Date: 04/26/2022
Date Signed: 04/26/2022 10:51:29 AM

Document Has Been Signed on 04/26/2022 10:51 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:AGING LOVELYFACILITY NUMBER:
486803334
ADMINISTRATOR:ALVIS, HIGINIAFACILITY TYPE:
735
ADDRESS:1148 HAYES STREETTELEPHONE:
(707) 421-1665
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 0DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Higinia Alvis, Licensee & AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Higinia Alvis, Licensee & Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. Currently, the facility does not have clients in care; last date clients were in the home was on 02/15/2022.
LPA toured the facility with Licensee. Fire extinguisher was charged and serviced on 07/23/2021.
The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff have received training from Solano County Public Health on the following topics: infection prevention, symptoms, transmission and PPE use. N-95 mask fit testing for staff (Cal/OSHA requirement) is in process. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing. All staff wore masks during this visit.
LPA requested the following updated records to be submitted to Community Care Licensing by 05/16/2022

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· Copy of current Administrator's Certificate
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

Exit interview conducted with Licensee, whose signature on this document confirms receipt.

No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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