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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803740
Report Date: 05/05/2022
Date Signed: 05/05/2022 04:50:45 PM

Document Has Been Signed on 05/05/2022 04:50 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:KALUSUGAN HOMES - BOXWOODFACILITY NUMBER:
486803740
ADMINISTRATOR:LEWIS-BARRETO, ANNABELLEFACILITY TYPE:
735
ADDRESS:2592 BOXWOOD LANETELEPHONE:
(707) 439-1816
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Alicia Valtierra Vazquez, Staff leadTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with staff lead Alicia Vazquez. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.
Facility has a screening station with sign-in sheet, COVID questionnaire, and hand sanitizer. LPA conducted a walk-through of the facility and observed 4 of 4 clients in care.
The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff have received training on COVID-19 infection prevention. Staff and client's temperatures are taken daily and documented. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. Staff stated they clean and disinfect the facility throughout the day. 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 discussed the following requirements with staff Alicia V.
· Facility to obtain N-95 mask fit testing for staff (Cal/OSHA requirement) - Technical Advisory Note was issued to the facility during this visit.
· Staff must wear face masks in the facility regardless of vaccination status - Technical Advisory Note was issued to the facility during this visit.
· COVID-19 vaccination requirements for staff specified in Provider Information Notice (PIN) 22-05.1-ASC (deadline for booster shots was 03/01/2022; weekly testing required for staff who have not completed the requirement).

*LPA will conduct a subsequent unannounced visit to the facility at a later time to verify staff COVID-19 vaccination and client P&I records. Licensee to have clear copies of vaccination cards for staff in file for CCL Review.
Report continued on LIC809-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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: KALUSUGAN HOMES - BOXWOOD
FACILITY NUMBER: 486803740
VISIT DATE: 05/05/2022
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LPA requested the following updated records to be submitted to Community Care Licensing by 05/23/2022
    · LIC 308 Designation of Facility Responsibility (1 per person)
    · LIC 500 Personnel Report
    · LIC 400 Affidavit Regarding Client/Resident Cash Resources
    · LIC 402 Surety Bond
    · LIC 610D Emergency Disaster Plan
    · LIC 9020 Register of Facility Clients
    · Copy of current Administrator's Certificate
    · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

Exit interview conducted with Staff Alicia, 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: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
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