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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803996
Report Date: 12/07/2021
Date Signed: 12/07/2021 02:02:21 PM

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:AGING IN THE BAY 2FACILITY NUMBER:
486803996
ADMINISTRATOR:MEDAROS, CHARMAINEFACILITY TYPE:
740
ADDRESS:1325 POTRERO CIRCLETELEPHONE:
(510) 388-7352
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:6CENSUS: 6DATE:
12/07/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Applicant, Charmaine MedarosTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Katrina Walters arrived unannounced and met with applicant, Charmaine Medaros, who will be the Administrator once the license is approved (Admin cert. 6050432740 exp 12/01/22). The purpose of this visit is to conduct a Pre-Licensing inspection. Facility is currently licensed as Parkview Care Home and the new facility will be a Change of Ownership. LPA conducted a risk assessment with staff, prior to entry. At the time of inspection, there were two staff providing care and supervision for six residents.

On the front door, LPA observed signs posted to promote the prevention of the spread of COVID-19. LPA was then greeted by staff. Staff did not check LPA's temperature or have them sign in, however LPA did observe a sign in sheet. LPA explained the importance of checking the temperature and symptoms of all visitors who enter. Both residents and staff are 100% vaccinated. Vaccination records are kept on file.

The facility has a fire clearance approval from the Suisun City Fire Department for 5 non-ambulatory, and 1 bedridden resident (bedrooms 1,2, 4 & 5 only) for a total of 6 residents. Facility will operate with two live-in staff and Licensee will ensure sufficient staffing at all times. This facility has two carbon monoxide detectors and six non-hardwired three hardwired smoke detectors, which were tested an appeared to be operational. Fire extinguisher last inspected 06/14/21. All exits were free from obstruction.

Continued on 809 C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: AGING IN THE BAY 2
FACILITY NUMBER: 486803996
VISIT DATE: 12/07/2021
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Continued from 809

Bathrooms were stocked with hand wash and paper product. There were grab bars and non-skid mats in both showers. Hand washing signs were posted. Faucets used by residents measured at 120 F. Resident's room's were furnished as required per regulation. Facility had at least a 30-day supply of incontinence products and personal protective equipment. Medications were in a locked cabinet. There was an ample of dishes and linen. Facility had sufficient perishable and non-perishable foods as required per regulation. All required posting were posted near the entrance of the facility.

Pre-licensing is complete and this facility has no deficiencies.

The Component III Orientation was completed during today's visit. LPA and Applicant discussed reporting requirements, operating requirement, fingerprint clearance & association, resident records...etc. LPA will submit the pre-licensing application report to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5