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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486803959
Report Date:
01/27/2023
Date Signed:
01/27/2023 01:56:31 PM
Document Has Been Signed on
01/27/2023 01:56 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:
SPECIAL CARE 2
FACILITY NUMBER:
486803959
ADMINISTRATOR:
AUJLA, HARJIT
FACILITY TYPE:
735
ADDRESS:
436 AMBER DRIVE
TELEPHONE:
(707) 981-1987
CITY:
SUISUN CITY
STATE:
CA
ZIP CODE:
94585
CAPACITY:
4
CENSUS:
4
DATE:
01/27/2023
TYPE OF VISIT:
Required - 1 Year
ANNOUNCED
TIME BEGAN:
01:15 PM
MET WITH:
Administrator/Licensee, Harjit Aujla
TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived announced on 01/27/2023 to conduct a required 1 - year inspection. LPA conducted inspection of licensee's sister facility prior to this inspection. This inspection is focused on the infection control practices and procedures of this care facility. LPA met with licensee/admin Harjit Aujla.
LPA toured building and grounds which were clean and in good repair. Exits and walkways were clear from obstructions. COVID postings and screening materials were present at the front entrance. High touch surface areas are disinfected daily. Facility has a sufficient amount of perishable and nonperishable food. Sufficient personal protective equipment was available to support a client in isolation. Toxins were locked and secured. Medications were locked and secured. Sharps were locked and secured. Fire extinguishers were charged and current. Carbon monoxide and smoke detectors were present throughout the facility. Staff and clients are fully vaccinated.
LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection:
LIC 308 Designation of Facility Responsibility
LIC 610 Emergency Disaster Plan
LIC 500 Personnel Report
LIC 9020 Client Roster
LIC 400 Affidavit regarding client cash resources
LIC 402 Surety Bond
Exit interview conducted with licensee/admin and a copy of this report emailed to the facility. No deficiencies cited during today's inspection.
SUPERVISORS NAME
:
Kimberley Mota
LICENSING EVALUATOR NAME
:
Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/27/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/27/2023
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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