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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803392
Report Date: 07/11/2023
Date Signed: 07/11/2023 12:02:09 PM


Document Has Been Signed on 07/11/2023 12:02 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:AVALON CARE HOME IIFACILITY NUMBER:
486803392
ADMINISTRATOR:ATWAL, PRITPAL K.FACILITY TYPE:
740
ADDRESS:5082 RASMUSSEN WAYTELEPHONE:
(707) 386-1042
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 6DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Pritpal "Meenu" Atwal, AdministratorTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Karina Canela arrived for the purpose of conducting a Required -1 Year inspection and met with Pritpal "Meenu" Atwal, Administrator.
LPA toured the facility, all exits were unobstructed. The facility was found to be clean & at a comfortable temperature. LPA observed a supply of linens (bedding, towels, etc.) and cleaning solutions (observed locked & inaccessible). Facility food supply was within regulation and accessible to residents. Medication was centrally stored; Administrator understands regulation 87465(h)(5) that medication shall be stored in its original container and pre-pouring medication (even up to 24 hours ) is not allowed. Water temperature was tested and observed between 105 to 120 degrees F.
Disaster Drills are conducted quarterly as required. Fire extinguisher was charged and purchased 06/2023. Smoke & carbon monoxide detector observed operational. LPA reviewed staff and resident records. Staff have current training certifications in First Aid & Cardiopulmonary Resuscitation (CPR) in file. Resident files are complete and up-to-date. 6 of 6 residents have doctor's orders for half rail use in file.

LPA requested the following updated forms to be submitted to Community Care Licensing by 08/11/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Liability Insurance
· LIC 9020 Facility Register of Client/Residents
· LIC 610E Emergency Disaster Plan
· Copy of current Administrator's Certificate

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
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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