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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803956
Report Date: 02/04/2022
Date Signed: 02/04/2022 12:27:43 PM

Document Has Been Signed on 02/04/2022 12:27 PM - 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:CONNECTED LIVING VACAVILLEFACILITY NUMBER:
486803956
ADMINISTRATOR:TRAIL, SARAFACILITY TYPE:
735
ADDRESS:82 MANZANITA DRIVETELEPHONE:
(925) 826-6830
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 3CENSUS: DATE:
02/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff, Cedric Tanner TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Walters arrived unannounced to conduct a REQUIRED 1 Year Annual Inspection and was greeted by staff, Cedric Tanner. This visit is focused on the infection control. This facility has not yet submitted a COVID-19 mitigation plan.

LPA toured the facility with staff and made observations. Facility was a clean and comfortable temperature. Rooms were furnished as required per regulation. Toxins are stored and not accessible. There was a supply of cleaners, hygiene products and paper products available for resident use.

LPA discussed the following with Staff regarding CCL requirements:
  • Screening station - screen all visitors for COVID-19 symptoms (including temperature check) & logging it.
  • Updated requirements for visitation listed in State Public Health Officer Order dated 12/31/2021 and CCL Provider Information Notice (PIN) 22-04-ASC.
  • COVID-19 staff training: infection prevention, symptoms, and transmission.
  • N-95 respirator Fit testing (Cal/OSHA requirement) for staff.
  • Facility to post posting to encourage droplet precautions.
  • Keeping a log of temperatures taken for clients and staff.
  • Reporting requirements
  • Completing the mitigation plan. (due by 2/7/22)


7 technical assistance advisory notes were issued today related to COVID-19 precautions and requirements. LPA is requesting that changes be made by 2/14/22. Exit interview conducted.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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