486803719-9-16-2022-21-AS-DTOA-CJBUF4-20220916153206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803719
Report Date: 09/16/2022
Date Signed: 09/16/2022 03:32:16 PM

Document Has Been Signed on 09/16/2022 03:32 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:	ACB CARE HOME		FACILITY NUMBER:	486803719
ADMINISTRATOR:	BULAUN, LEAFAR		FACILITY TYPE:	740
ADDRESS:	118 UNIVERSITY AVE		TELEPHONE:	(707) 552-0484
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	09/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Leafar Bulaun, Administrator		TIME COMPLETED:	03:45 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	On 9/16/2022, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Licensee, Leafar Bulaun (LB). The facility currently provides care for 5 residents none 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 Licensee, 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. Smoke and carbon monoxide detectors were tested and in working order. Fire extinguisher was last charged 8/4/2022. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for residents. LPA conducted a sample file review and found all staff to have updated CPR & First Aid Training. Toxins are stored in a locked facility garage. Sharps and additional cleaning supplies are found under the kitchen sink and found to be secured. Auditory alarms at all exits were tested and found to be in working order. There was a supply of hygiene products and paper products available and provided upon request or when needed. All resident bedrooms have lighting & appropriate furnishings. Medications and facility records are secured in cabinets located in facility living room. LPA measured water at faucets accessible to residents which measured at 91.1 degrees F which is not within Title 22 regulations between 105 and 120 degrees F. Facility to complete and submit 7-day water log in order to ensure compliance. Technical Assistance issued. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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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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: ACB CARE HOME	FACILITY NUMBER: 486803719
	VISIT DATE: 09/16/2022

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Infection Control:
Facility has submitted an infection control plan to CCLD for review. All residents and staff are vaccinated with no symptoms. Posters have been placed at the front door and throughout the facility, along with 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 daily basis or based on change of condition.

No citations issued during today's visit.

LPA requested the following documents be sent to CCL by COB 9/23/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility resident’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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