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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803865
Report Date: 04/08/2022
Date Signed: 04/08/2022 04:32:58 PM

Document Has Been Signed on 04/08/2022 04:32 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:LUCIA'S HOMEFACILITY NUMBER:
486803865
ADMINISTRATOR:ABILLAR, VAL HENRYFACILITY TYPE:
737
ADDRESS:7952 CHARLOTTE LANETELEPHONE:
(707) 392-4258
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Mark Mercado, Lead StaffTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Staff, Mark Mercado (MM). Administrator, Val Abillar (VA) was not available for today's visit, but was available by phone. There were four staff providing care and supervision for four clients.

The following observations were made: The facility has designated the garage as the single entrance for all visitors. Once in the garage, staff sign in visitors using a sign-in sheet. Staff check visitors temperature and oxygen level prior to entering. Signs are posted on the wall to promote droplet precaution and alert visitors of their visiting policy. Spare disposable mask and gloves are made available.

The facility was a clean and comfortable temperature of 70 degrees. All staff were wearing face coverings. LPA toured the facility with MM. All clients bedrooms were furnished as required per regulation. Sinks in the kitchen and bathroom were stocked with liquid soap and paper products. Signs were located near all sinks to promote proper hand washing techniques. LPA observed a 60 day supply of PPE and incontinence products in garage. Trash pales have lids, to prevent the spread of airborne viruses.

LPA reviewed 5 staff records. 5 of 5 personnel files included copies of vaccine cards, and training on infection control and the facilities mitigation/infection control plan. All staff have been fit-tested for N-95 mask. 4 of 4 clients vaccine cards were stored in their file. As apart of this visit, LPA conducted interviews with staff and clients.

No deficiencies cited during today's inspection. exit interview conduct with Mark Mercado and Val Abuilar by phone.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
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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