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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803865
Report Date: 05/26/2021
Date Signed: 05/26/2021 12:40:29 PM

Document Has Been Signed on 05/26/2021 12:40 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LUCIA'S HOMEFACILITY NUMBER:
486803865
ADMINISTRATOR:ABILLAR, VAL HENRYFACILITY TYPE:
737
ADDRESS:7952 CHARLOTTE LANETELEPHONE:
(650) 269-5687
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Val AbillarTIME COMPLETED:
12:50 PM
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At approximately 10:30 AM Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator, Val Abillar (VA). Licensee Dalmacio Lete (DL) was also present. At the time of inspection there were 5 staff providing care and supervision for 4 clients. During the visita two clients left for an outing, the other two clients were resting in their room.

LPA observed that proper signage was posted at the entrance and through out the facility to promote hand washing and social distancing. Upon entry, LPA was screened for COVID-19 symptoms using a temperature gun. LPA was then signed-into the facility visitor log.
Disposable mask and hand sanitizer were available. The facility was found to be clean and at a comfortable temperature of 68 degrees with all exits free from obstruction. There was one entry point for the facility.

LPA toured the facility with VA and staff. Client's temperatures are check daily and logged on a Medication Administration Record (MAR). Clients' medications are stored in a closet in the kitchen. Facility has a 30-day supply of medication for residents. Bathrooms were stocked with paper towel and hand washing supplies. Signs were also posted in staff and client bathrooms as a reminder to wash hands. All staff were wearing mask. Per VA the facility infection control nurse is scheduled to be fit test all staff for N95 mask. LPA provided Administrator with a copy of PIN 21-10. Facility has a supply of PPE stored in the garage. Resident's emergency contact information has been updated and Emergency Personnel numbers are posted at the facility. LPA has reviewed and approved the facility mitigation plan.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2021
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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