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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803677
Report Date: 10/24/2022
Date Signed: 10/24/2022 12:45:59 PM

Document Has Been Signed on 10/24/2022 12:45 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:A RESIDENCEFACILITY NUMBER:
486803677
ADMINISTRATOR:ALVIS, HIGINIAFACILITY TYPE:
735
ADDRESS:2264 CAMBRIDGE DRIVETELEPHONE:
(707) 631-3655
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 5CENSUS: 4DATE:
10/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Higinia Alvis, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Higinia Alvis, Administrator; Alejandra Arciga, Direct Support Professional was also present. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.
LPA toured the facility, all exits were unobstructed. Facility has a COVID-19 screening station (visitor sign-in sheet, COVID questionnaire, thermometer, hand sanitizer). Fire extinguisher was charged and serviced 05/17/2022. The facility has an supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. The facility has submitted their Infection Control Plan to the California Department of Social Services, Community Care Licensing. Staff have received refresher training on Proper Utilization of PPE, Infection Prevention & Control, and Environmental Cleaning to Prevent COVID-19 and other Infectious Diseases from Solano County Public Health on 01/11/2022. Staff have current CPR/first aid certifications in file. During this visit, LPA verified staff COVID-19 vaccination records. LPA verified documentation on N-95 Respirator FIT testing for designated staff (Cal/OSHA requirement) was completed. All staff wore face masks during this visit.
LPA requested the following updated forms to be submitted to Community Care Licensing by 11/21/2022:
    · LIC 308 Designation of Facility Responsibility (1 person per form)
    · LIC 500 Personnel Report
    · LIC 400 Affidavit Regarding Resident Cash Resources (indicate if not handling cash for residents)
    · Surety Bond
    · LIC 610D Emergency Disaster Plan
    · LIC 9020 Register of Facility Residents/clients
    · Copy of current Administrator's Certificate
    · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
Exit interview conducted with 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: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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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