486803843-9-5-2023-21-AS-DTOA-CVDQU7-20230905122817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803843
Report Date: 09/05/2023
Date Signed: 09/05/2023 12:28:22 PM

Document Has Been Signed on 09/05/2023 12:28 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:	PROVIDENCE RESIDENTIAL CARE - LAKEHURST		FACILITY NUMBER:	486803843
ADMINISTRATOR:	LEWIS-BARRETO, ANNABELLE		FACILITY TYPE:	740
ADDRESS:	409 LAKEHURST COURT		TELEPHONE:	(707) 439-1816
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	4	CENSUS: 4	DATE:	09/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Nancy Rojas, House Supervisor		TIME COMPLETED:	12:45 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	9/5/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Lead Staff, Arlene Ponce De Leon and House Supervisor, Nancy Rojas. Licensee, Annabelle Lewis-Barreto was contacted but was unable to attend the visit. The facility is single story building licensed for 4 non-ambulatory residents. The facility currently provides care for 4 residents, 3 of which were present and 1 of which was attending day program. There are currently no residents receiving hospice services but some of which have a diagnosis of dementia. LPA continued with a tour of the facility with Lead Staff and House Supervisor, 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 3/9/2023. Both smoke detectors and carbon monoxide detectors throughout the facility were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with additional food supplies in the garage. Facility also follows appropriate dietary protocol for resident in care. Toxins were located in the garage and laundry room both of which were found to be secured. LPA toured the facility backyard and found all bedroom screens in good repair and found one emergency exits located in the side yard to be clear and unobstructed. Two storage sheds located in the backyard were also found to be locked and secured. Residents were observed in their bedrooms watching television or interacting with staff in the common areas. There was a supply of hygiene products and paper products available for residents. All resident bedrooms have lighting & appropriate furnishings. Water at faucets accessible to residents was measured within regulation. Medications located in dinning area were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Store Medication Record. LPA found that the facility inputs start dates on the Medication Administration Record (MAR). LPA advised facility staff to input medication start dates on the CSMR form moving forward. Upon medication count LPA found all administered medication to be in order. 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: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

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: PROVIDENCE RESIDENTIAL CARE - LAKEHURST	FACILITY NUMBER: 486803843
	VISIT DATE: 09/05/2023

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LPA conducted a file review for all 4 out of 4 residents and found all items including Physician's Reports and Needs & Service Plans to be updated. The facility conducts quarterly assessments for each resident or upon changes of condition. LPA also conducted a sample file review for staff and found all staff to have appropriate 1st aid & CPR and annual training on file. LPA and House Supervisor conducted a spot P&I count for residents and found all monies to be in order and not commingled.

Licensees Annabelle Lewis-Barreto's Administrator Certification 6015066740 is valid until 11/19/2024. Ruben Poblete's Administrator Certification 6049157740 is valid until 11/19/2024.

LPA requested the following documents be sent to CCL by COB 10/5/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Proof of ownership or lease/rental agreement

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

LIC809 (FAS) - (06/04)

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