486803925-10-19-2020-21-AS-KCAA-BUJNZY-20201019105508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803925
Report Date: 10/13/2020
Date Signed: 10/19/2020 10:55:27 AM

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:	AMEERA CARE		FACILITY NUMBER:	486803925
ADMINISTRATOR:	MONES, MA. JOWAHER		FACILITY TYPE:	740
ADDRESS:	2568 BOXWOOD LANE		TELEPHONE:	(925) 818-6415
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	6	CENSUS: 6	DATE:	10/13/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Ma. Jowaher Mones		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) K. Canela conducted a pre-licensing inspection at Ameera Care on 10/13/2020 by virtual calling. Due to COVID – 19 precautions, a facility visit is not able to be conducted at this time. LPA met with applicant Ma. Jowaher Mones, who will be the administrator once the facility is approved for licensure.
LPA observed no visitors signs at the front entrance. A screening area is inside the front door which includes, temperature taking, hand sanitizer and sign in log. Licensee applicant will ensure staff wear masks in the facility as a COVID-19 precaution.
The facility has a fire clearance approval by the Fairfield Fire Department for 6 non-ambulatory, a total capacity of 6 residents. Facility will operate with a live-in staff and Licensee will ensure sufficient staffing at all times. LPA observed all exits and walkways to be unobstructed. Required postings such as Complaint poster, Rights to resident councils, and client's rights were observed.
Toxin storage were located in locked cabinets/closets throughout the facility. Medications are centrally stored and observed locked. Sharps and knives are stored in separate locked cabinet/containers and inaccessible to residents in care. The facility has extra linens and hygiene supplies available for residents in care. LPA observed 1 carbon monoxide detector and 9 smoke detector alarms which were tested and observed to be operational. Two fire extinguishers were observed charged and serviced on 11/13/2019. LPA observed adequate food supply per current census. Facility has a small dog, observed interacting with residents as pet therapy. Licensee-to-be shall ensure the dog is non-aggressive with residents and visitors.
Resident rooms were furnished per regulation. Grab bars and non-slip mats were observed in bathrooms. Night lights were observed in hallways and passageways to non-private bathrooms. Exit doors are alarmed and functional. LPA and Applicants discussed COVID processes for mitigating and containment if necessary.

Pre-Licensing is complete and this facility has no deficiencies. The Component III Orientation was completed with applicant on 10/14/2020.

LPA will submit the pre-licensing application report to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

*signature in file

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Karina Canela	TELEPHONE: (707) 588-5083
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2020

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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