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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803688
Report Date: 09/27/2022
Date Signed: 09/27/2022 01:30:39 PM


Document Has Been Signed on 09/27/2022 01:30 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:SOLANO QUALITY HOME CAREFACILITY NUMBER:
486803688
ADMINISTRATOR:PRAKASH, SNEH LATAFACILITY TYPE:
740
ADDRESS:266 DE SOTO DRIVETELEPHONE:
(707) 386-3600
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 3DATE:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Patricia Kurpieski, caregiver TIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Patricia Kurpieski, caregiver. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. LPA conducted a tour of the facility with Patricia, all exits were observed unobstructed. The facility has a screening station, LPA was screened upon arrival. LPA observed COVID-19 precaution postings. The facility has submitted their Infection Control Plan to be reviewed by the California Department of Social Services, Community Care Licensing. LPA verified staff's vaccination status for COVID-19 during this visit.
LPA discussed the following with Caregiver:
    · Facility to obtain N-95 mask fit testing for staff (Cal/OSHA requirement)
    · Postural Supports
    · Maintain a 30 day supply of Personal Protective Equipment (PPE) in the facility
    · Staff First Aid requirements
    · Document resident's temperatures on a daily basis.
LPA requested the following updated forms to be submitted to Community Care Licensing by 10/24/2022:
    · LIC 308 Designation of Facility Responsibility (1 person per form);
    · LIC 500 Personnel Report;
    · LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents);
    · Liability Insurance
    · LIC 610E Emergency Disaster Plan;
    · LIC 9020 Register of Facility Residents;
    · Copy of current Administrator's Certificate
    · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
· LPA requested documentation of physician's orders and exception request for bedrails to be submitted to CCL immediately
Exit interview conducted with Caregiver, whose signature on this document confirms receipt.
*No deficiencies cited at this time during inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
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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