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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803677
Report Date: 09/20/2021
Date Signed: 09/22/2021 09:13:11 AM

Document Has Been Signed on 09/22/2021 09:13 AM - 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:A RESIDENCEFACILITY NUMBER:
486803677
ADMINISTRATOR:ALVIS, HIGINIAFACILITY TYPE:
735
ADDRESS:2264 CAMBRIDGE DRIVETELEPHONE:
(707) 631-3655
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 5CENSUS: 3DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Higinia Alvis, AdministratorTIME COMPLETED:
03:34 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Higinia Alvis, Administrator. 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 staff and observed COVID-19 precaution postings. LPA and Administrator discussed implementing a screening station at front entrance of facility to screen anyone entering the facility (staff, essential and non-essential visitors). Screening station to include hand sanitizer, a thermometer, COVID-19 screening questionnaire, and a sign-in sheet for visitors and staff. LPA discussed requirements and guidance from Provider Information Notice (PIN) 21-40-ASC.
Administrator stated client's temperatures are taken once a day. LPA discussed with Administrator documenting daily temperatures for clients and staff. LPA discussed documenting staff training on infection prevention, symptoms, transmission and PPE use.
Staff clean and disinfect the facility 1-2 times daily. Administrator stated high touched surface areas are disinfected daily. The facility has a designated visitation area and provides phone calls for family to stay in contact with clients. LPA observed 2 clients in care, 1 client was at school. N-95 respirator Fit testing (Cal/OSHA requirement) is in process. The facility has a supply of PPE including gloves, face shields, 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.
All staff wore masks during this visit.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
Due to printer malfunction, this report was emailed to Administrator.
No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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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