486803666-6-14-2024-21-AS-SMUU-D68T2X-20240614142129

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803666
Report Date: 06/14/2024
Date Signed: 06/14/2024 02:21:35 PM

Document Has Been Signed on 06/14/2024 02:21 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

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: 4	DATE:	06/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Imee Villegas, Licensee		TIME COMPLETED:	02:35 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	At approximately 11:00 AM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced annual required inspection of this licensed senior care facility. LPA was greeted by Mirna Santiago,caregiver. Administrator, Imee Villegas arrived shortly after. The facility is a single story home licensed for six (6) non-ambulatory residents one can be bedridden and a hospice waiver capacity of two (2). The facility currently provides care for 4 residents. In addition, there is one resident on hospice and there are some residents with a diagnosis of dementia. At approximately 11:15 AM, LPA and Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked cabinet in the facility laundry room, garage, kitchen and in backyard. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen drawer and cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Water temperature measured within regulation between 118 and 120 degrees F at three of three faucets accessible to residents. One out of one fire extinguisher was inspected and charged. Seven out of seven Smoke detectors were present and Carbon Monoxide detector was present. There was enough lighting in all common areas, resident rooms, and hallways. Emergency disaster drills are conducted quarterly with the last emergency disaster drill conducted on 05/15/2024. Continued on LIC809-Ca

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CASA ISABELLA	FACILITY NUMBER: 486803666
	VISIT DATE: 06/14/2024

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Continued from 809

Facility provides a family atmosphere with games, puzzles,and television in living room. Each resident room is equipped with a television. The facility temperature measured 73 degrees with air conditioning running. Air purifiers are located throughout the facility. Resident on hospice had one caregiver providing one on one assistance. Medications located in designated cabinet were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Resident was observed interacting with staff in bedroom and living room. Two of four residents were found in their room. Two of four residents were observed in the living room socializing and watching television. LPA observed staff checking and caring for residents often.

At approximately 12:15 PM, LPA reviewed Four of four resident records which were all found to be well organized, thorough and contained the required documentation. At approximately 1:00 PM , LPA reviewed three out of three staff records which were all found to be well organized, thorough and contained the required documentation. Medication records are thorough and contained physician's orders for each resident.
Administrator Imee Villegas Administrator Certification 7009121740 is expired as of 06/09/2024. Administrator provided proof of required CU and recertification re-submission. Administrator confirmed application was received as of 05/06/2024

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

LIC 500 Personnel Summary
LIC 9020 Register of Facility Client’s/Resident'
Evidence of Liability Insurance

No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

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