<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803378
Report Date: 05/27/2022
Date Signed: 05/27/2022 10:55:28 AM

Document Has Been Signed on 05/27/2022 10:55 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:CARE GREATFACILITY NUMBER:
486803378
ADMINISTRATOR:ZHANG, GUOLIAN (MARK)FACILITY TYPE:
735
ADDRESS:3265 VISTA DEL LAGO WAYTELEPHONE:
(707) 427-8776
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Zhenying (Jenny) Liu, caregiverTIME COMPLETED:
11:14 AM
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) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Zhenying (Jenny) Liu, direct caregiver. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.
Facility has a screening station with sign-in sheet, COVID-19 questionnaire and thermometer. Zhenying (Jenny) Liu took LPA's temperature upon arrival and screened for COVID symptoms. The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff and client's temperatures are taken daily and documented. Staff clean and disinfects the facility on a daily basis. Facility has COVID-19 precaution postings and liquid hand soap available in the bathrooms. 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.
LPA discussed the following requirements with the facility staff:
· Facility to obtain N-95 mask fit testing (not training) for staff (Cal/OSHA requirement).
· Paper towels required to be available in bathrooms.
· Immediately notify Community Care Licensing (CCL) of any epidemic outbreaks/cases or incidents & submit a report.
LPA requested the following updated documents to be submitted to Community Care Licensing by 06/16/2022:
· LIC 308 Designation of Facility Responsibility · LIC 500 Personnel Report · LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash resources) · LIC 402 Surety Bond (if handling P&I for clients) · LIC 610D Emergency Disaster Plan · LIC 9020 Register of Facility Clients · Copy of current Administrator's Certificate · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
Exit interview conducted with staff Jenny, whose signature on this document confirms receipt. ** Administrator was unavailable, LPA will return at later date to review additional items.
*No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1