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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803417
Report Date: 01/18/2022
Date Signed: 01/18/2022 04:54:20 PM

Document Has Been Signed on 01/18/2022 04:54 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:ST. JUDE CARE HOME IIFACILITY NUMBER:
486803417
ADMINISTRATOR:DEVERA, ROSEFACILITY TYPE:
735
ADDRESS:2613 ELMHURST CIRCLETELEPHONE:
(707) 389-4631
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
01/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Dinah Belandres, back-up-administrator/Live-in staffTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Dinah Belandres, co-administrator, who wore a mask during the inspection. 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 co-administrator and observed COVID-19 precaution postings. A sign-in area was observed at front entrance of facility which had hand sanitizer and a sign-in sheet for visitors. The facility has designated visitation areas, provides virtual visits and phone calls for family to stay in contact with clients. Co-administrator stated staff and client's temperatures are taken once a day.
LPA observed 4 clients in care. 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 (CCL).
LPA discussed the following with co-Administrator Dinah Belandres regarding CCL requirements:
· Screening station - screen all visitors for COVID-19 symptoms (including temperature check) & logging it.
· Updated requirements for visitation listed in State Public Health Officer Order dated 12/31/2021 and CCL Provider Information Notice (PIN) 22-04-ASC.
· COVID-19 staff training: infection prevention, symptoms, and transmission.
· N-95 respirator Fit testing (Cal/OSHA requirement) for staff.
· Facility to ensure clients have liquid hand soap, toilet paper, and paper towels accessible in all bathrooms
· Keeping a log of temperatures taken for clients and staff.

9 technical assistance advisory notes were issued today related to COVID-19 precautions and requirements.

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: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2022
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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