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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803926
Report Date: 11/28/2022
Date Signed: 11/28/2022 10:02:34 AM


Document Has Been Signed on 11/28/2022 10:02 AM - 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: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:
11/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Eva Mulder, Administrator & LIcenseeTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Eva Mulder Administrator & Licensee. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA toured the facility, all exits were unobstructed, and the facility was found to be clean and at a comfortable temperature. Facility has a COVID-19 screening station (visitor sign-in sheet, COVID questionnaire, thermometer, hand sanitizer). Smoke detectors and carbon monoxide detector were tested and observed operational. Fire extinguisher was charged and serviced 12/20/2021. The facility has an ample supply of food, linens, and hygiene products available. Staff clean and disinfect the facility throughout the day. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. Staff have received refresher training on PPE donning & doffing, Infection Prevention & Control, and Environmental Cleaning to Prevent COVID-19 and other Infectious Diseases from Solano County Public Health on 02/01/2022.

LPA requested the following updated forms to be submitted to Community Care Licensing by 12/28/2022:
    · LIC 308 Designation of Facility Responsibility (1 person per form)
    · LIC 500 Personnel Report
    · LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
    · Copy of liability insurance
    · LIC 610E Emergency Disaster Plan
    · Copy of current Administrator's Certificate
    · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
Exit interview conducted with Administrator whose signature on this document confirms receipt.
**No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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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