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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803378
Report Date: 05/10/2024
Date Signed: 05/16/2024 09:14:09 AM

Document Has Been Signed on 05/16/2024 09:14 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CARE GREATFACILITY NUMBER:
486803378
ADMINISTRATOR/
DIRECTOR:		ZHANG, GUOLIAN (MARK)FACILITY TYPE:
735
ADDRESS:3265 VISTA DEL LAGO WAYTELEPHONE:
(707) 427-8776
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
05/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Silva (Silvia) Rosario, House Manager & LIcensee/Administrator, Zhang (Mark) Guolian TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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At approximately 8:50AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by House Manager, Silva (Silvia) Rosario. Licensee/Administrator, Zhang (Mark) Guolian was called and and he informed House Manager that he was on his way to the facility. LPA observed 3 other Direct Support Professionals (DSP) present and was informed that all 3 live in the facility. Facility is an Adult Residential Facility with Developmentally Disabled Clients in care. LPA observed 2 of 3 clients home and was informed 1 of 3 clients was away at day program. LPA was informed 2 clients were home because of behaviors which have made placing them in a day program challenging. Both require one-to-one supervision. House Manager informed LPA that facility is working with North Bay Regional Center.

At approximately 9:20AM, LPA initiated a tour of the facility with House Manager. LIcensee/Administrator arrived at approximately 9:35AM. During facility inspection, LPA observed the following: Facility was a comfortable temperature and passageways were free from obstructions. Water temperature in clients' bathrooms measured between 105 and 112 degrees F, which is within allowable range of 105 to 120 degrees F per regulation. LPA observed facility does not have clients' rights or the CCL information and reporting poster placed in a conspicuous place in a common area as required per regulation. LPA advised Licensee to obtain and post these. LPA observed a supply of clean linens available to clients.

LPA inspected 3 of 3 clients' bedrooms and observed one room missing blinds, closet doors and a chair. House Manager stated the client took the closet doors off and does not want blinds or a chair. All rooms otherwise have the appropriate furnishings as outlined in Title 22 regulations.

Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods and a supply of bottled water, as well as emergency supplies and flashlights.

Continued on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CARE GREAT
FACILITY NUMBER: 486803378
VISIT DATE: 05/10/2024
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Continued from LIC809

LPA observed a weekly menu and activity schedule posted in the common living area. Laundry room and garage doors were locked and LPA was informed that they remain locked. Medications were centrally stored and locked. There is outdoor space for clients and the grounds are safe, clean and orderly. LPA observed a locked shed in the backyard which is used solely for storage.

The facility is hardwired. Fire extinguisher is charged and was last serviced April 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts bi-annual disaster drills. LPA informed Licensee and House Manager that disaster drills shall be conducted quarterly on both day and evening shifts moving forward. The most recent drill was conducted March 2024. LPA observed the facility's infection control plan, first aid kit, and emergency disaster plan which are all in compliance with regulation.

At approximately 10:20AM 4 staff files and 3 client files were reviewed and all have the required documentation per regulation. All staff have current required training, First Aid certificates, and all have current CPR as well. All staff have been background screened, cleared, and are associated to the facility per regulation.

LPA observed medications centrally stored and locked. LPA reviewed medications and medication records which are maintained within regulation. LPA reviewed P&I monies and logs, which were organized and maintained to accurately reflect the amount of money on hand. Licensee has a surety bond amount sufficient to cover money held for clients in care and money is not commingled.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610D- Disaster Plan
Resume - For New Administrator
New Administrator Certificate

No deficiencies cited.

Exit interview conducted with Licensee whose signature on this document confirms receipt. This report was reviewed with Licensee/Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC809 (FAS) - (06/04)
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