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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803926
Report Date: 10/15/2020
Date Signed: 10/16/2020 09:50:27 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:EVAS CARE HOMEFACILITY NUMBER:
486803926
ADMINISTRATOR:MULDER, EVAFACILITY TYPE:
740
ADDRESS:319 ATLANTIC AVETELEPHONE:
(510) 890-8777
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:3CENSUS: 0DATE:
10/15/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Eva Mulder (Applicant)TIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Cuadra conducted the Pre-licensing Inspection and Component III via video conferencing due to Covid-19 precautions with Applicant, Eva Mulder.

LPA/Applicant toured the inside of the facility and grounds via video conference. This is a one-story residence with four bedrooms including master bedroom (office room), one full bathrooms and one half bathroom, living room and kitchen. All facility bedrooms have all personal accommodations. Residents bedrooms had the required furnishings, such as a dresser, nightstand, lamp and bed linens. There are two common bathrooms with a shower equipped with nonskid mats but no grab bars for safety. Facility received an approved fire clearance October 1, 2020 that allows for three non-ambulatory residents. LPA did not observed required postings (LTCO, CCL Complaint poster, visitor policy, employee rights and personal rights). in addition to COVID-19 required visitation postings were not observed. LPA will provide Covid-19 posters and discussed with Applicant the importance of creation of mitigation plan. LPA provided PIN 20-38 and PIN 20-28 for Applicant to review. All appliances in the kitchen were working properly. Applicant showed LPA the contents of their First Aid Kit. Applicant couldn't test the water because did not have a thermometer.

Facility provides assistance with family communication via telephone or video call. Facility needs to
There is a locked cabinet that will be used for medications. Binders for client, staff and medication were observed in lockable cabinet. LPA informed cleaning supplies and toxins will be locked in a cabinet in laundry room or locked on storage outside of laundry room. Amble supply of linens, hygiene products, cooking utensils, pots/pans and dishes observed. Perishable and non-perishable foods observed per regulation. Facility has space indoors and outdoors for resident activities. The facility has a working telephone for residents in care.

Continues on LIC809...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: EVAS CARE HOME
FACILITY NUMBER: 486803926
VISIT DATE: 10/15/2020
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Fire extinguisher was charged on September 9, 2020. Applicant tested smoke detectors and carbon monoxide and were operational. Exit doors does not have auditory alerts installed. LPA discussed facility's Disaster Preparedness with Applicant. Administrator Certificate # 6050341740 expires 9/22/2021. Component III Orientation was completed with Applicant. LPA will conduct inspection after above items are submitted to confirm complete. After confirmed LPA will notify Application Unit pre-licensing inspection is complete and to proceed with licensure.

LPA will provide this report to the Centralized Application Unit to continue application process.

Applicant agrees to submit the following items for LPA review:


· proof of lockable cabinet for medications.
· proof of lockable cabinet for toxins.
· proof of lockable cabinet for knives.
· proof of required postings (LTCO, emergency plan/numbers, CCL complaint poster, Client personal rights and visitor policy)
· proof of thermometer and log of at least seven days to certify that water temperature is within regulation.
· proof of auditory alarms.

No deficiencies found during today's inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020
LIC809 (FAS) - (06/04)
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