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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803882
Report Date: 12/15/2023
Date Signed: 12/18/2023 04:20:52 PM


Document Has Been Signed on 12/18/2023 04:20 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:CASA ISABELLA IIFACILITY NUMBER:
486803882
ADMINISTRATOR:VILLEGAS, ART GFACILITY TYPE:
740
ADDRESS:680 SNAPDRAGON PLTELEPHONE:
(707) 344-0839
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY:6CENSUS: 5DATE:
12/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Art Villegas, Administrator TIME COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Canela arrived unannounced, to conduct an Annual Required 1 YR inspection and was greeted by care staff, and Licensee/Administrator, Art Villegas.

LPA toured facility and grounds and observed all required signs posted in common areas. Infection control practices are present. Facility has a 30-day supply of PPE. Facility has also submitted their Infection Control plan, which is a part of their Plan of Operation. Facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days supply of perishable and one week of non-perishable foods, LPA reminded facility to use proper freezer bags to store items that are not in the original container. Fire Extinguishers were fully charged, and have proof of service on 12/14/2023. Smoke detectors and carbon monoxide detectors were operational. Fire drills are conducted every three months.. Water temperature in the resident bathroom was tested and found to be within appropriate range of 105-120 degrees. Exit doors have auditory alarms to alert staff. The bedrooms are all furnished as required. Bathrooms were clean and sanitary with non-skid mats/floors and grab bars.

Resident and staff files are located and locked in office. LPA reviewed resident files and staff files. Staff have proof of required annual training and CPR/1st Aid certificates expiring 12/2024.


Continue report See LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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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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: CASA ISABELLA II
FACILITY NUMBER: 486803882
VISIT DATE: 12/15/2023
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LPA discussed Emergency Disaster Plan and Infection Control Plan. LPA went over Community Care Licensing links that LPA will email to facility to view informational PINS, Guardian and quarterly updates.

During todays visit, LPA requested facility to review and get clarification on resident R1 ambulatory status and update LPA by 12/21/2023. LPA also provided guidance and forms needed to be submitted to Community Care Licensing for any changes in the facility ambulatory/non-ambulatory/bedridden room use.

Licensee/Administrator to submit all the below documents to LPA by 1/20/2024 and LPA will review and update file.



· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report-
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of Liability Insurance-
Copy of Administrator Certificate


No citations issued during todays inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC809 (FAS) - (06/04)
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