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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803775
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:11:34 PM

Document Has Been Signed on 09/12/2024 03:11 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ISABELLA'S HOMEFACILITY NUMBER:
486803775
ADMINISTRATOR/
DIRECTOR:		SELENE CRUZ-ASTORGAFACILITY TYPE:
737
ADDRESS:915 GOLD COAST CTTELEPHONE:
(707) 759-3784
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Selene Cruz-Astorga, Licensee/Administrator & Angelica Gonzalodo, Staff/Responsible PartyTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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At approximately 9:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Angelica Gonzalodo, Responsible Party (RP). Selene Cruz-Astorga, Licensee/Administrator was contacted and arrived at approximately 9:45 AM. LPA was then informed that RP would be facilitating today's inspection. Facility is an Enhanced Behavioral Support Home (EBSH) with four (4) clients in care; one (1) of whom is non-ambulatory and three (3) are ambulatory. LPA was informed that Client 1 (C1) was out of the facility at Day Program and the other three (3) clients were present during today's inspection. Facility is vendorized with North Bay Regional Center (NBRC).

At approximately 10:00 AM, LPA initiated a tour of the facility with RP and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, paper products, and incontinent care products available to clients. Clients' bedrooms were inspected and observed to have all of the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA was informed that C1 is high functioning, is working towards being independent again, and wishes to store and manage their own laundry detergent and cleaning chemicals. LPA advised RP and Licensee that "these items shall be stored where inaccessible to clients" per Health and Safety Code (HSC) Section 80087(g). Further, LPA advised RP and Licensee to consult with C1's physician and get something in writing stating that C1 is ok to manage these items on their own, update C1's IPP to reflect this, and assist C1 with securing any such items in their room where inaccessible to other clients in care. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded area in the backyard with outdoor space for activities. LPA was informed that facility has a recreational therapist and a music therapist who visit the facility weekly.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ISABELLA'S HOME
FACILITY NUMBER: 486803775
VISIT DATE: 09/12/2024
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Continued from LIC809...

RP plans regular outings, decorates for holidays and facility has games, instruments, sensory activities, and iPads available for clients in care. Facility has internet service and the phone was tested an operational during today's inspection.

Facility is equipped with a Talco fire sprinkler system and designated water tank which is located in the garage. Facility's fire extinguisher was observed charged and was last serviced December 2023. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills with the last one conducted July 2024 and monthly fire drills, with the last one conducted September 2024. LPA observed facility's infection control plan and emergency disaster plan which was last updated June 2024. LPA observed a supply of PPE, emergency supplies, multiple first aid kits, flashlights, and a backup generator for emergency preparedness.

At approximately 12:30 PM, LPA reviewed four (4) staff files and four (4) client files. Four (4) of four (4) staff files reviewed have all the required paperwork and proof of current First Aid and CPR training. Four (4) of four (4) client files reviewed have all the required paperwork. Staff coordinate medical and dental visits for the clients and take them to their appointments.

At approximately 2:00 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. LPA reviewed P&I monies and logs, which were organized, maintained, and stored in accordance with regulation.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC500 - Personnel Report (updated)

No deficiencies cited during today's inspection. Exit interview conducted with RP whose signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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