486803925-10-4-2023-21-AS-CFOR-CWAS9L-20231004134056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803925
Report Date: 08/29/2023
Date Signed: 10/04/2023 01:41:27 PM

Document Has Been Signed on 10/04/2023 01:41 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	AMEERA CARE		FACILITY NUMBER:	486803925
ADMINISTRATOR:	MA JOWAHER CARABBACAN MAGA		FACILITY TYPE:	740
ADDRESS:	2568 BOXWOOD LANE		TELEPHONE:	(925) 818-6415
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	6	CENSUS: 6	DATE:	08/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Elsa Magaoay, Asst. Administrator		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 9:15AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a Required 1 Year annual inspection and met with Asst. Administrator, Elsa Magaoay. Administrator Ma Jowaher Carabbacan Magaoay arrived at approximately 11:15AM to introduce herself and left shortly after. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 6 non-ambulatory residents total capacity of 6 residents. Facility has an approved hospice waiver for 3 individuals. LPA conducted a tour of the facility and observed the following: the facility was clean and at a comfortable temperature with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Toxins were secure and not accessible to residents. There is a sufficient supply of hygiene products, paper products, and linens available for resident use. Mattress pads were in place or available for resident use. Medication was centrally stored and secure. LPA reviewed 5 of 6 resident records. During review of resident records,LPA reviewed a sample of staff records. LPA reviewed 5 staff files. All files were found to be organized with proper documentation. Administrator's Certificate (6055095740) was current with an expiration date of 01/15/2024 and Assistant Administrator Certificate (600843740) is current and expires on 12/10/2023. LPA and Administrator discussed facility's emergency and evacuation plan. The facility's last fire and evacuation drill was conducted June 21, 2023. Facility's fire extinguishers were last inspected 10/27/2022. Smoke detectors and carbon monoxide detectors were tested and operational. The amount of fresh and non-perishable foods are within regulation. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. LPA conducted staff and resident interviews. Continued on LIC809C.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AMEERA CARE	FACILITY NUMBER: 486803925
	VISIT DATE: 08/29/2023

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Continue from LIC809

LPA requested the following documents to update facility file:

· Designation of Facility Responsibility (LIC 308)
· Control of Property
· Emergency Disaster Plan (LIC 610D)
· Health Screening Report for Administrator (LIC 503)
· Updated Personnel Report (LIC 500)
· Register of Clients/Residents (LIC 9020)
· Updated Liability Insurance
· Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Tuesday, 09/05/2023

No deficiencies cited, exit interview conducted. Copy of this report provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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