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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803965
Report Date: 04/21/2022
Date Signed: 04/21/2022 11:34:28 AM

Document Has Been Signed on 04/21/2022 11:34 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:ANTIQUITY HOME, LLCFACILITY NUMBER:
486803965
ADMINISTRATOR:ORIBELLO, MARK & GRACEFACILITY TYPE:
735
ADDRESS:904 ANTIQUITY DRIVETELEPHONE:
(408) 313-0173
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 3DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Mark Oribello TIME COMPLETED:
11:44 AM
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At approximately 10:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct an Annual Inspection visit and was greeted by Administrator, Mark Oribello. Administrator, Grace Oribello arrived later during the visit. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival at the facility, LPA had their temperature checked and logged. LPA answered a standard COVID-symptom questionnaire. LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

Facility has a cleaning and disinfecting schedule that occurs daily. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for clients. Staff and Clients are screened daily for COVID-19 symptoms and it is logged into facility binders.

LPA and Administrator discussed N-95 Fit testing, activities, and PPE. Facility has a plan in place if a staffing shortage were to occur.

Continued on LIC 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ANTIQUITY HOME, LLC
FACILITY NUMBER: 486803965
VISIT DATE: 04/21/2022
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Continued from LIC-809

Fire extinguishers were last serviced July 2021. Fire Alarms and Carbon Monoxide detectors were tested and operational.

LPA and Administrator discussed a recent special incident report/SOC341 regarding C1, C2, and C3. C1 pulled C2's shirt and attempted to reach for his neck and throat. Staff intervened and C1 attempted to grab C3 too. Staff intervened again and redirected clients.
Per conversation with Administrator, C1 is a fairly new client and has recently started to exhibit these behaviors. Facility is in contact with C1's family, North Bay Regional Center, and their physician. C1's behaviorist has been coming weekly. Facility will be having a meeting today regarding C1 to assist in de-escalating their behaviors.

No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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