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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803361
Report Date: 11/29/2021
Date Signed: 11/29/2021 03:48:16 PM

Document Has Been Signed on 11/29/2021 03:48 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:SAMSON HOME CARE 1FACILITY NUMBER:
486803361
ADMINISTRATOR:SAMSON, EVELYN M.FACILITY TYPE:
735
ADDRESS:3122 SAN ANTONIO COURTTELEPHONE:
(707) 421-2394
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
11/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Co-Administrator Joanne Samson TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and was greeted by live-in staff Carmencita (Cita) L. Co-Administrator Joanne Samson arrived later. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.
LPA conducted a walk-through of the facility with live-in staff and observed COVID-19 precaution postings. A screening station was observed at front entrance of facility which had hand sanitizer, a thermometer, and a sign-in sheet for visitors and staff. LPA was screened for COVID-19 symptoms. Visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. LPA discussed the requirement for indoor visitation requirement of verifying COVID-19 vaccination or a negative COVID test within 72 hours for non-essential visitors. The facility has designated visitation areas, provides virtual visits and phone calls for family to stay in contact with clients. Staff and client's temperatures are taken once a day; LPA observed documentation. Staff clean and disinfect the facility every night. LPA observed paper towels, hand soap, and hand washing steps poster in the bathroom.
LPA observed 3 clients in care. Staff have documented completion on the following training: infection prevention, symptoms, transmission and PPE use. N-95 respirator Fit testing (Cal/OSHA requirement) is in process with North Bay Regional Center. The facility has a supply of PPE including gloves, face shields/goggles, N-95 respirators, surgical masks and disposable gowns.

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.

Exit interview conducted with co-Administrator, 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: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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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