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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803869
Report Date: 08/03/2022
Date Signed: 08/03/2022 01:56:03 PM

Document Has Been Signed on 08/03/2022 01:56 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: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:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Hydee Ramirez, AdministratorTIME COMPLETED:
02:10 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 Administrator, 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 purchased new on 8/24/21. Smoke and carbon monoxide detectors were tested and functioning. Administrator conducts smoke alarm checks every two weeks and logs the information. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Sharps were located in a designated kitchen cabinet and found to be inaccessible to clients. Toxins and cleaning supplies are stored under the kitchen sink and in a storage area located in the backyard which were locked and secured. There was a supply of cleaners, hygiene products and paper products available for clients. All clients bedrooms have lighting, appropriate furnishings and linen supplies.

Water temperature at faucet accessible to clients was measured at 110.1 degrees F, which is within Title 22 regulations. LPA conducted review of staff 1st Aid & CPR certification and found training up to date. During inspection tour LPA observed client bedroom window screen and backyard sliding door screen to be in disrepair.

Infection Control:
Facility has submitted a COVID Program Plan to CCLD for review. Staff and clients are all vaccinated and boosted with symptom and temperature checks conducted on a daily basis or by observed changes of condition. Posters have been placed throughout the facility and restroom indicating COVID mitigation protocols. Lastly, facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: HYDEE'S CARE HOME LLC
FACILITY NUMBER: 486803869
VISIT DATE: 08/03/2022
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Hydee Ramirez's Administrator certification 60511180735 is up to date and expires 6/3/2023.

LPA requested the following documents be sent to CCL by COB 8/17/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Certificate of Liability Insurance

Exit interview conducted with facility Administrator, whose signature on this document confirms receipt.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/03/2022 01:56 PM - It Cannot Be Edited


Created By: Dominic Tobola On 08/03/2022 at 01:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HYDEE'S CARE HOME LLC
FACILITY NUMBER: 486803869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 window screens which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2022
Plan of Correction
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Licensee failed to ensure facility is in good repair at all times. Licensee agrees to replace window screens observed to be in disrepair. Photo of repairs to be sent to CCL by Plan of Correction date 8/17/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


LIC809 (FAS) - (06/04)
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