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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803719
Report Date: 09/02/2021
Date Signed: 09/02/2021 02:36:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ACB CARE HOMEFACILITY NUMBER:
486803719
ADMINISTRATOR:BULAUN, LEAFARFACILITY TYPE:
740
ADDRESS:118 UNIVERSITY AVETELEPHONE:
(707) 552-0484
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Leafar Bulaun, AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Leafar Bulaun (LB).The facility currently provides care for 6 residents, 3 of which are on hospice and some with a diagnosis of dementia.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 9/26/2021 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the facility laundry room and garage. LPA observed bleach cleaning supply in resident bathroom accessible to residents in care. The cleaning supply was immediately removed and stored in a secured garage. Water temperature was measured at 115.3 degrees F at faucets accessible to residents which is within regulation between 105 and 120 degrees F. There was a supply of cleaners, hygiene products and paper products available for residents. All resident bedrooms have lighting & appropriate furnishings.

Infection Control:
Facility has submitted a mitigation program plan which has been reviewed. All residents and staff are vaccinated with no symptoms. Staff receive COVID testing on a weekly basis. Posters have been placed at the front door, and facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Staff and residents are screened for temperature and symptoms on a daily basis and recorded.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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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