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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803953
Report Date: 03/08/2022
Date Signed: 03/08/2022 11:46:03 AM

Document Has Been Signed on 03/08/2022 11:46 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:HIGH POINTE RESIDENCESFACILITY NUMBER:
486803953
ADMINISTRATOR:CHILDS, WESTLUNDFACILITY TYPE:
735
ADDRESS:1737 YORK ST.TELEPHONE:
(707) 712-8038
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 1DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dante Ward, Licensee TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Dante Ward, Licensee. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.
LPA conducted a walk-through of the facility with licensee and observed COVID-19 precaution postings and a screening station at front entrance. The facility has designated visitation areas, provides virtual visits and phone calls for loved ones to stay in contact with clients. LPA observed 1 client in care. Staff have First Aid and CPR certifications. The facility has a supply of PPE including gloves, N-95 respirators, and surgical masks. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing.

LPA discussed the following requirements with Licensee:
· Documenting staff daily temperatures and COVID symptom screening questionnaire.
· Screening station visitor sign-in sheet to include a section for COVID-19 screening questionnaire and section to document verification of COVID-19 vaccination (or negative COVID-19 test) for indoor visitation.
· Wearing masks regardless of vaccination status.
· Staff training on the following topics: infection prevention, symptoms, transmission and PPE use.
· N-95 respirator Fit testing (Cal/OSHA requirement) for staff. Licensee to obtain documentation for completion for CCL verification.
· Conducting and documenting earthquake and fire drills every 3 months
· Fire extinguisher to be serviced for 2022 (observed charged).
· Follow up with North Bay Regional Center to obtain client's records needed for the facility file.

Exit interview conducted with Licensee, whose signature on this document confirms receipt.
No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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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