486803525-1-19-2023-21-AS-DTOA-CN93EZ-20230119171200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803525
Report Date: 01/19/2023
Date Signed: 01/19/2023 05:12:10 PM

Document Has Been Signed on 01/19/2023 05:12 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:	DARWIN FACILITY		FACILITY NUMBER:	486803525
ADMINISTRATOR:	HALL, MYRTLE		FACILITY TYPE:	735
ADDRESS:	1612 TUCSON CIRCLE		TELEPHONE:	(707) 426-4981
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY: 4		CENSUS: 2	DATE:	01/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:54 PM
MET WITH:	Joanna Hall, Lead Staff		TIME COMPLETED:	05:15 PM

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	On 1/19/2023, Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by Lead Staff, Joanna Hall. The facility currently provides care for 2 clients, both of which where attending day program at the time of visit. LPA was informed that the facility is undergoing the removal process of bedbugs. The facility is in contact with the Terminex exterminator company, who have been providing services once per month until the bedbugs are fully removed. LPA continued with a tour of the facility with Lead Staff; facility was found to be at a comfortable temperature with all exits free from obstruction. Common areas, kitchen & food storage areas were inspected. LPA did not inspect client bedrooms due to recent bedbug infestation and directive from CCLD Management. The fire extinguisher located in facility dinning area and client hallways were found to be last charged on 1/9/2023 at the time of the visit. There was a sufficient supply dishes, silverware and both perishable and nonperishable foods. Food was also found to be stored properly as per Title 22 Regulations with a variety of nutritious food options. In addition, clients and staff discuss planned snacks and meals based on client preferences. Toxins are stored in locked cabinets located in the facility garage which was kept secured. There was a supply of cleaners, hygiene products and paper products available for clients. Backyard emergency exits were unobstructed and easily accessible. LPA observed roof/ceiling repairs in place due to rain water leaking to the front entrance from recent weather. Staff stated that the repairs are still in the process with no expected finish date. The leaking however has been stopped. LPA also conducted a spot check of staff files and found all staff to have 1st Aid & CPR certification on file. Continued onto LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: DARWIN FACILITY	FACILITY NUMBER: 486803525
	VISIT DATE: 01/19/2023

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
26
27
28
29
30
31
32

During the tour, LPA observed bedbugs that appeared to be dead along the corners of several walls located in the resident hallways. LPA was unable to determine whether the bedbugs where alive or remains (Photos taken). Staff stated that bedbugs are mainly located in client bedrooms. Staff contacted Terminex and confirmed that the last service to exterminate bedbugs was on 1/3/2023. The company will be contacting staff in the next several days to schedule an upcoming visit next month. Staff agrees to clean up bedbug remains observed during the visit.

Infection Control:
Facility has submit a infection control plan which has been submitted for review. Posters have been placed at the front door, and facility has a station in the staff office near facility entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. LPA recommended for staff to continue screening clients for temperature and symptoms on a daily basis. Clients are also screened for transportation and upon entering their Day Programs.

LPA requested the following documents be sent to CCL by COB 1/25/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance

The Department is requesting for Licensee to attend a Regional Office meeting to address difficulties in contacting Licensee leading to inaccessibility for the Department to conduct facility inspections on several occasions. Date TBD.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal Rights Given.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/19/2023 05:12 PM - It Cannot Be Edited

Created By: Dominic Tobola On 01/19/2023 at 04:26 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: DARWIN FACILITY	FACILITY NUMBER: 486803525
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above regarding bedbug remains found in several locations throughout the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2023
	Plan of Correction
1 2 3 4	Licensee agrees to clean facility of any insect remains or debris throughout the facility and client bedrooms and submit a LIC9098 Proof of Corrections form along with photo proof of corrections to CCLD by POC due date 1/20/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Kimberley Mota

LICENSING EVALUATOR NAME:

Dominic Tobola

LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3