486803926-10-30-2023-21-AS-CFOR-CWBPF8-20231005111619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803926
Report Date: 10/05/2023
Date Signed: 10/30/2023 09:16:52 AM

Document Has Been Signed on 10/30/2023 09:16 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	EVAS CARE HOME		FACILITY NUMBER:	486803926
ADMINISTRATOR:	MULDER, EVA		FACILITY TYPE:	740
ADDRESS:	319 ATLANTIC AVE		TELEPHONE:	(510) 890-8777
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	3	CENSUS: 0	DATE:	10/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Eva Mulder, Administrator		TIME COMPLETED:	11:45 AM

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	Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced Required 1 Year Inspection and met with Administrator, Eva Mulder. This three (3) bed facility serves elderly residents, during the visit facility has a capacity of 0 residents. On today's inspection. LPA inspected facility and observed: Facility is clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher located in the kitchen was found to be charged and serviced on 8/21/2023 and within regulation requirements. Smoke detectors and Carbon monoxide detectors were found to be operational during the visit. Hot water temperature in residents bathrooms measured within Title 22 acceptable regulation of 105 to 120 degrees F. There was a supply of both perishable and nonperishable foods. The refrigerator was clean and food stored properly. Toxins are stored in key locked cabinets, under kitchen sink. There was an ample supply of hygiene products, linens and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. All bedrooms have lighting & appropriate furnishings. Required postings viewable in public areas. LPA reviewed location of resident's medication will be centrally stored and locked. LPA reviewed facility records: Administrator Certificate of Eva Mulder #6050341740 expired September 22, 2023 Administrator applied for renewal in July 2023 and is waiting for renewed certificate. LPA reviewed staff record. See LIC809-C for continuation of report

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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: EVAS CARE HOME	FACILITY NUMBER: 486803926
	VISIT DATE: 10/05/2023

NARRATIVE

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Continued from LIC809

LPA is requesting the following documents be submitted to CCL in order to update facility file by 10/18/2023:

LIC 308 Designated
LIC 309 Administrative Organization
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Control of property
Administrator Certificate
Certificate of Liability Insurance

Exit interview conducted with Administrator, a copy of this report was provided.

No deficiencies cited during this inspection

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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