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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803852
Report Date: 04/08/2022
Date Signed: 04/08/2022 01:51:18 PM

Document Has Been Signed on 04/08/2022 01:51 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:THRIVE ADULT RESIDENTIAL CARE II, INC.FACILITY NUMBER:
486803852
ADMINISTRATOR:MARIA GOLITZENFACILITY TYPE:
735
ADDRESS:2340 CABOT CTTELEPHONE:
(510) 689-4911
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Maria Golitzen, AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and was greeted by staff Sid Cereno. Administrator Maria Golitzen arrived later. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.
LPA conducted a walk-through of the facility. LPA observed 2 of 4 clients in care; one was on an outing with staff Glen and the other was out in the community independently. Staff have CPR/first aid certifications. Fire extinguisher was charged and serviced 10/19/2021.
The facility has a supply of PPE including gloves, N-95 respirators, gowns, face shields, and surgical masks. Staff have received training on the following topics: infection prevention, symptoms, transmission and PPE use. Staff and client's temperatures are taken daily and documented. Administrator stated staff 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. Administrator completed N-95 Fit testing (Cal/OSHA requirement). Administrator stated she would complete for other staff as well. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms.
The facility combination smoke/carbon monoxide detectors, (6 total) were tested and observed operational.

LPA discussed the following requirements with Administrator:
· Facility to ensure all visitors are being screened for COVID-19, including temperature check.
· Facility to verify vaccination status of visitors for indoor visitation & document
· Staff must wear masks in the facility regardless of vaccination status.

Exit interview conducted with Administrator, 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: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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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