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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803824
Report Date: 07/20/2021
Date Signed: 07/20/2021 04:12:44 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:CHENIN BLANC ASSISTED LIVINGFACILITY NUMBER:
486803824
ADMINISTRATOR:JONES, NIKIYAHFACILITY TYPE:
740
ADDRESS:5326 CHENIN BLANC PLACETELEPHONE:
(707) 208-6451
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:4CENSUS: 0DATE:
07/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator, Nikiyah JonesTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Chenin Blanc Assisted Living for the purpose of conducting an Required-1 year inspection. LPA was greeted at the front door by Nikiyah Jones who granted access into the facility. Facility census is currently 0 and also employs no staff as of yet.

LPA toured the facility with the Administrator. The home was a comfortable temperature, was clean and in excellent condition. Smoke detectors and carbon monoxide detector were tested and operational. The fire extinguishers located in the kitchen and hallway were new and inspected during the Fire Safety Inspection. There are auditory alerts on exit doors which were tested and functional. Water temperature in the resident bathrooms were within the required range of 105 to 120 degrees Fahrenheit. Bathrooms have required non-skid surfaces and grab bars. Cleaning products are stored in the locked garage. Knives are stored in a locked cabinet in the kitchen. There is adequate space and furniture on the patio for outdoor activities. There was a 7 day supply of non-perishable foods. There are adequate dishes, glasses and silverware for food service. Laundry equipment was present. There were emergency lighting supplies and batteries present. There is a locked cabinet that will store residents' medications and a cabinet that will store resident and staff files.

In addition, LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Staff have had all PPE training required. Administrator has been N95 Fit tested.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Nikiyah Jones.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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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