486803925-9-20-2024-21-AS-JFLO-D9AVVC-20240920164608

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803925
Report Date: 09/20/2024
Date Signed: 09/20/2024 04:46:14 PM

Document Has Been Signed on 09/20/2024 04:46 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:	ELSA MAGAOAY		FACILITY TYPE:	740
ADDRESS:	2568 BOXWOOD LANE		TELEPHONE:	(925) 818-6415
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	6	CENSUS: 6	DATE:	09/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Elsa Magaoay, Administrator		TIME COMPLETED:	05:00 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 2:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Elsa Magaoay, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6 ) residents in care. All residents were present during today's inspection. Facility has a hospice waiver for three (3), a bedridden waiver for one (1), is approved for all non-ambulatory residents, and currently has two (2) hospice residents in care. At approximately 2:10 PM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a covered seating area in the backyard with outdoor space for activities. LPA observed two locked sheds in the backyard which LPA inspected and observed the contents of both to consist of tools, chemicals, decorations, extra incontinent care products, and extra facility equipment such as mattresses and a shower chair. LPA observed an activity schedule and was informed that the facility has teamed up with a Solano County Developmental Group who comes to the facility twice a week to conduct activities with residents and was informed by a resident that they play games, paint the residents' nails, and perform exercises each week. Facility has an internet access device and internet service available to residents in care and the telephone was tested an operational during inspection. Facility's fire extinguisher was observed charged and was last serviced November 2023. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Continued on LIC809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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: 09/20/2024

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Continued from LIC809C...

Facility conducts quarterly disaster drills, and the most recent drill was conducted July 2024. LPA observed the facility's infection control plan, first aid kit, PPE, other emergency supplies, and a back-up generator. LPA reviewed facility's emergency disaster plan last updated June 2024.

At approximately 3:20 PM, five (5) staff files were reviewed. All staff files reviewed have all of the required paperwork including the required CPR and First Aid training certificates and documentation of all required initial and annual training hours.

Licensee states facility and residents' families work together to coordinate medical and dental appointments and transportation to and from visits. Facility does not manage cash resources for residents. **LPA will return at a later date to complete this annual inspection consisting of resident file and medication record review.

No deficiencies were cited during inspection.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

Copy of New Facility Lease

Exit interview conducted with Administrator whose signature on form confirms receipt.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC809 (FAS) - (06/04)

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