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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803959
Report Date: 08/27/2021
Date Signed: 08/27/2021 12:32:22 PM

Document Has Been Signed on 08/27/2021 12:32 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SPECIAL CARE 2FACILITY NUMBER:
486803959
ADMINISTRATOR:AUJLA, HARJITFACILITY TYPE:
735
ADDRESS:436 AMBER DRIVETELEPHONE:
(707) 981-1987
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 4DATE:
08/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Harjit Aujla, Licensee and AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Post Licensing Inspection and met with Harjit Aujla, Licensee and Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility that has four residents.

LPA observed a screening station at the entrance of facility which had hand sanitizer, a thermometer, and a sign-in station for visitors. Visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Staff and clients' temperatures are taken at least once a day and are documented. LPA conducted a walk-through of the facility with Administrator and observed COVID-19 precaution postings at the entrance to building,. LPA observed facility was a comfortable temperature. Fire Extinguisher was up to date and easily accessible. LPA randomly tested water temperature at the facility and it was within regulation. All exits were unobstructed and doors were operational.

Staff clean and disinfect the facility daily. High touched surface areas are disinfected after each use. The facility allows vistitation outside with masks, and provides virtual visits and has a house phone. Residents are waiting for day programs to open.

Administrator reported that they require new residents and new hires to be Covid -19 tested prior to admittance or hire, and 25% of staff and residence are surveillance-tested twice a month. Facility staff have completed training on infection prevention, symptoms, transmission and PPE use. N-95 respirator Fit testing is in process.
LPA observed a supply of PPE including: gloves, face shields, N-95 respirators, surgical masks and gowns. All staff wore a face mask during this visit. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 to the California Department of Social Services.

Exit interview conducted with Harjit Aujla, whose signature on this document confirms receipt.


No deficiencies cited during this inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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