486803949-4-26-2021-21-AS-KWAS-C2FSWJ-20210426141425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803949
Report Date: 04/23/2021
Date Signed: 04/26/2021 02:14:59 PM

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:	ST JOSEPH CARE HOME		FACILITY NUMBER:	486803949
ADMINISTRATOR:	LIM, RAQUEL VICTORIA		FACILITY TYPE:	740
ADDRESS:	829 HARRIER DRIVE		TELEPHONE:	(510) 809-6912
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 2	DATE:	04/23/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:38 AM
MET WITH:	Victoria Lim		TIME COMPLETED:	04:30 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	Licensing Program Analyst (LPA) K. Walters spoke with Applicant, Victoria Lim, this date virtually. The purpose of this tele-visit is to conduct a Pre-Licensing inspection. The inspection is being conducted virtually due to COVID - 19 precautions. The reader is advised that the LPA was not physically present during today’s visit. Carbon monoxide alarms were operational. The fire extinguisher was last inspected on 07/16/2020. The facility is one story with 4 bedrooms, 2 baths, office room, staff room, and a fenced back yard. The outside grounds were free of any apparent hazards, and fire exits were clear. No bodies of water. No firearms. Patio area comfortably furnished with an awning for shade. The interior living room, dining room and kitchen were adequately furnished. LPA observed that auditory alarm was turned off in the living room. After learning of this, Applicant then turned on the alarm. Required posting were observed. Facility has a small table at front entrance, that will be used for screening visitors and staff. The table has hand sanitizer, thermometer, sanitizing wipes, paper towels and a garbage can. At 3:15 PM LPA observed that 3 of the 5 smoke detectors were inoperable. Suisun City Fire Department granted the facility a clearance on 11/11/2020 for 6 non-ambulatory residents. LPA observed locked cabinets for resident and staff records observed in the office. Medications were locked in the kitchen cabinets. Kitchen was spacious and clean, adequate supply of dishes and utensils. Cleaning supplies were locked under the kitchen sink. Continued on 9099 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ST JOSEPH CARE HOME	FACILITY NUMBER: 486803949
	VISIT DATE: 04/23/2021

NARRATIVE

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Continued from 9099

LPA observed a clean refrigerator, with nonperishable and perishable foods. Three food items were found to be expired.(pictures taken) The facility has two refrigerators, a freezer, kitchen cabinets and several shelves with can/dry goods, paper products and emergency water.

Laundry room was observed. laundry supplies were observed in the garage and additional linens were in hallway cabinets. Bathrooms were supplied with slip mats. Bedrooms were observed to be clean with adequate dressers and closet space for belongings. LPA observed a knife in Bedroom 3, which was accessible to persons with dementia.

A subsequent Pre-Licensing inspection is needed to ensure the following items are corrected and reviewed: Comp 3 will be conducted during the next visit.

· Updated facility sketch to reflect to reflect correct facility layout.
· Applicant will ensure all sharps are locked and inaccessible to individuals with dementia.
· Applicant will ensure that all smoke detectors are operable and alarms are on.
· The Applicant understands that prior to accepting clients they should have: Physician’s Report 602, needs and service appraisal and admission agreements.
· The applicant will ensure the shed is locked and not accessible to residents in care.

This pre-licensing is incomplete. The above items are to be resolved by 4/28/21. A follow up Pre-licensure LIC809 will be generated upon resolution of listed items above. LPA will submit the pre-licensing reports to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

Copy of report to be scanned/emailed to Applicant for signature and will be final printed upon receipt.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021

LIC809 (FAS) - (06/04)

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