<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803713
Report Date: 01/27/2022
Date Signed: 01/27/2022 12:48:04 PM

Document Has Been Signed on 01/27/2022 12:48 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:RUTHIE'S HOMEFACILITY NUMBER:
486803713
ADMINISTRATOR:ROBIN BRANDONFACILITY TYPE:
735
ADDRESS:3789 CLAY BANK RDTELEPHONE:
(707) 673-2047
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 2DATE:
01/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Raquel Cistac, House Manager TIME COMPLETED:
01:00 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) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Raquel Cistac, House Manager. 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 Raquel Cistac, House Manager. A screening station was observed at front entrance of facility which had hand sanitizer, a non-touch thermometer, and a sign-in sheet for visitors and staff. LPA was screened for COVID-19 symptoms and temperature was taken. Visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Staff verify visitor's vaccination status and a negative COVID test per PIN 22-04-ASC and State Public Health Officer Order dated 12/31/2021 (LPA verified documentation).
Staff and resident's temperatures are taken daily. Staff clean and disinfect the facility throughout the day. The facility has a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and disposable gowns. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. 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. LPA observed 2 residents in care. House Manger wore masks during this visit.

LPA discussed the following CCL requirements with Raquel Cistac :
· Staff training documented in the following areas: infection prevention, symptoms, transmission and PPE use
· N-95 respirator Fit testing (Cal/OSHA requirement) for staff.

The following forms were requested to update the facility administrator (to be submitted to CCL by 02/11/2022): LIC215, LIC500, LIC308, LIC501, copy of Administrator’s certificate

Exit interview conducted with house Manger, 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: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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 3