486803709-4-12-2022-21-AS-KWAS-CDEREC-20220412125719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803709
Report Date: 04/12/2022
Date Signed: 04/12/2022 12:58:26 PM

Document Has Been Signed on 04/12/2022 12:58 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:	NANAY HOME LLC		FACILITY NUMBER:	486803709
ADMINISTRATOR:	LEILANI JOCSON		FACILITY TYPE:	735
ADDRESS:	369 BISHOP DRIVE		TELEPHONE:	(707) 999-5267
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY: 4		CENSUS: 4	DATE:	04/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:02 AM
MET WITH:	Leilani Jocson, Administrator		TIME COMPLETED:	01:07 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	Licensing Program Analyst (LPA) Walters arrived unannounced for the purpose of conducting a Required 1 Year annual inspection. LPA met with Leilani Jocson, Administrator. Licensee, Irene Monteclar arrived later. This visit will focus on the infection control of this facility. The facility submitted an infection control mitigation plan on 06/07/2021 which was approved by Community Care Licensing. On the entrance door of the facility, signs are posted to ensure all visitors wear mask, and to conduct a self symptom check prior to entry. Upon entry there is a sign-in sheet, with disposable, N-95 mask and hand sanitizer. LPA toured the facility with Administrator and made the following observations: All client's bedrooms were clean, had appropriate lighting, and furnished as required per regulation. Each bedroom was equipped with a disinfection stations which include hand sanitizer wipes and gloves. Trash can's with lids are placed outside of bedroom to prevent the spread of airborne illnesses. Clients toys and games are placed in a basket after usage to be disinfected. Continued on 809 C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NANAY HOME LLC	FACILITY NUMBER: 486803709
	VISIT DATE: 04/12/2022

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
26
27
28
29
30
31
32

Facility has a 30 day supply of incontinence products, Personal Protective Equipment (PPE) and medication as allowed by their physician. Facility keeps an inventory of all PPE and incontinence products. Toxins and other items that can pose a risk to clients in care are key locked in garage cabinets. Per Administrator, Licensee, and records reviewed facility is disinfected three times per a shift, which is documented on logs and signed by staff. Facility has a supply of water, at least a 5 day supply of non-perishable, and 2 day supply of perishable foods in the event of an emergency. Snacks were available for clients.

LPA reviewed staff and client records, records reveal that staff and clients are 100% vaccinated and have begun getting their fourth booster. Staff have been trained on infection control, droplet precaution and the usage personal protective equipment. Facility keeps a binder of the most updated PINS available for staff and responsible parties. Administrator and staff discuss Pins in their meetings, meeting notes documented in staff records. Facility has also updated clients emergency disaster plan and emergency contacts.

A first aid kit is stocked and available. Fire extinguisher throughout the facility were charged and serviced 8/30/21. Carbon Monoxide and Smoke Detectors were tested appeared to be operational. Facility purchased a generator, which is checked monthly by staff. Staff check water temperature weekly and document it on log.

Nothing further.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2