486803666-8-5-2021-21-AS-KWAS-C5LQYA-20210805123448

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803666
Report Date: 08/05/2021
Date Signed: 08/05/2021 12:34:57 PM

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:	CASA ISABELLA		FACILITY NUMBER:	486803666
ADMINISTRATOR:	VILLEGAS, IMEE C		FACILITY TYPE:	740
ADDRESS:	3060 DUKE CIRCLE		TELEPHONE:	(707) 398-7539
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95688
CAPACITY:	6	CENSUS: 6	DATE:	08/05/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:33 AM
MET WITH:	Administrator, Imee Isabella		TIME COMPLETED:	12:45 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	Licensing Program Analysts (LPA), Katrina Walters arrived unannounced to conduct an Annual inspection at approximately 10:30 AM, and met with Administrator, Imee Isabella (II). LPA conducted a risk assessment with II prior to entering the facility. The inspection is focused on the Infection Control procedures and practices of this facility. Mitigation plan has been submitted and approved by Community Care Licensing (CCL). Upon entry, LPA was screened and had temperature checked prior to entering. Visitors have their own entrance, where they are signed in, screened and can visit with residents. Alcohol based hand wash and disposable mask was available at both entries. At approximately 10:45 AM LPA conducted walkthrough of facility with administrator and made the following observations: Facility had all required postings visible for visitors. Additional posters were posted throughout the facility to promote handwashing and social distancing. Facility was a comfortable temperature and exits were free from obstructions. Bathrooms were stocked with hand soap and paper towel. Per Administrator, they regularly discuss infection control with residents and staff. Changes in protocol are communicated to responsible parties via phone or email. Staff have completed Personal Protective Equipment (PPE), infection control training by Solano County Public Health. Facility has 60+ day supply of PPE located in the garage. Facility is cleaned daily and high touch surfaces are cleaned each shift and after every meal. (Continued on LIC 809-C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: CASA ISABELLA	FACILITY NUMBER: 486803666
	VISIT DATE: 08/05/2021

NARRATIVE

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All exit alarms on exit doors were working properly. Fire Extinguisher was found to be last charged on March 2, 2021 at the time of the visit. There were 6 Facility smoke detectors and 2 carbon monoxide detectors that were found to be functioning properly at the time of the visit. There was a sufficient supply for both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit.

The following document is being requested from administrator and will be submitted by 8/19/21: Physician order for resident R1's bed.

No deficiencies observed or cited during today's Required 1- Year inspection.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC809 (FAS) - (06/04)

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