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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803691
Report Date: 09/02/2022
Date Signed: 09/02/2022 04:47:04 PM

Document Has Been Signed on 09/02/2022 04:47 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:ADELAIDE HOMEFACILITY NUMBER:
486803691
ADMINISTRATOR:JOCSON, LEILANIFACILITY TYPE:
735
ADDRESS:615 CHRISTINE DRIVETELEPHONE:
(415) 990-9617
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 4DATE:
09/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Dulce SickmenTIME COMPLETED:
04:56 PM
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Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced 1-year annual required inspection of this facility. LPA was greeted by house manager, Dulce Sickmen. The Administrator Leilani Jocson arrived later. At the time of the inspection there were 3 staff, a nurse and 1 house manager providing care and supervision for 4 clients.

LPA toured the building and grounds which were found to be clean and in good repair. Smoke and carbon monoxide detectors were tested and appeared to be operational. The fire extinguisher was last serviced 08/30/22. All exits were unobstructed. The facility has a current emergency disaster plan that has been approved by licensing. Emergency disaster plan is posted in the facility. Per the Licensee and Administrator, the sprinklers and smoke detectors were last inspected by Hue and Cry inspection on 6/21/22. The Administrator will send LPA a copy by 9/6/22.

Prior to entering the facility there is a sign posted directing visitors to disinfect shoes. At the primary entrance LPA observed temperature log, visitor sign in sheet spare N-95 mask and hand sanitizer. There was at least a 30 day supply of incontinence products, Personal Protective Equipment and Cleaning Supplies. Additional supplies in storage. All bedrooms have a disinfection station for clients and staff use, which include gloves, hand sanitizer and mask. Signs were posted throughout the facility to promote droplet precaution.

Emergency lighting was available in all client rooms and in the hallways. Bedrooms were furnished with chairs, dressers, beds with padding and appropriate lighting. Bathroom's had hand washing supplies and paper products were available. LPA observed adequate emergency food and water supply. Toxins were secured under the kitchen sink and garage. In addition, all knives and other sharp items were found to be in a locked location in the kitchen. Medication was locked in a file cabinet. Staff disinfect the facility three times a shift and as needed, which is documented on a staff checklist.

LPA requested that the facility sends current copy of Liability Insurance, Emergency Disaster plan and current LIC 500 to Santa Rosa Community Care Licensing attention Katrina Walters.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2022
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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