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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803869
Report Date: 08/20/2021
Date Signed: 08/20/2021 01:27:15 PM

Document Has Been Signed on 08/20/2021 01:27 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:HYDEE'S CARE HOME LLCFACILITY NUMBER:
486803869
ADMINISTRATOR:RAMIREZ, HYDEEFACILITY TYPE:
735
ADDRESS:1175 JACK LONDON DRIVETELEPHONE:
(707) 704-8353
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 3DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Hydee Ramirez, LicenseeTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Licensee, Hydee Ramirez (HR).The facility currently provides care for 3 clients all of which were present at the time visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire extinguisher was last charged on 1/29/2019. Licensee has reached out to Fire Marshal for inspection but has not received services due to COVID restrictions. Licensee to contact Fire Marshal and schedule inspection date. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a storage area located in the backyard which was found to be accessible to clients. Storage area was immediately locked during the visit. There was a supply of cleaners, hygiene products and paper products available for clients. All clients bedrooms have lighting & appropriate furnishings.

Infection Control:
Facility has completed a mitigation program plan which has been reviewed during today's visit. All clients and staff are vaccinated with no symptoms. Staff and clients are over 70% vaccinated but continue surveillance testing for all staff on a weekly basis. Posters are readily available to staff and clients for COVID procedures, and facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature on daily basis.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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