<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804007
Report Date: 12/20/2021
Date Signed: 12/20/2021 01:14:23 PM

Document Has Been Signed on 12/20/2021 01:14 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:INFINITI CARE HOME #1FACILITY NUMBER:
486804007
ADMINISTRATOR:MARTUSCELLO, JULIEFACILITY TYPE:
735
ADDRESS:607 TRAVIS BLVDTELEPHONE:
(707) 771-1516
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
12/20/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Julie Martuscello, ApplicantTIME COMPLETED:
01:23 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Karina Canela conducted a pre-licensing inspection on 12/20/2021. LPA met with Applicant Julie Martuscello who will be the Administrator when the facility is approved for licensure. The facility does not have any pending waiver requests. The facility has a fire clearance approval from the Fairfield Fire Department of 4 non-ambulatory for a total capacity of 4. Facility will operate with a live-in staff and Licensee will ensure sufficient staffing at all times.
    During today’s visit LPA observed the following items:
    · COVID-19 postings and screening station at entrance
    · Lockable separate cabinets for medications, toxins, and knives.
    · All exits were unobstructed
    · 7 smoke detectors & 1 carbon monoxide detector, which were tested and observed to be operational
    · First Aid kit, night-lights, and flashlights for emergency lighting
    · Supply of linens, paper products, and hygiene supplies available .
    · Fire Extinguisher charged and serviced 03/17/2021
    · Required furnishings in all 4 resident bedrooms
    · Administrator Certification (EXP: 07/23/2023)
    · Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, and visitor policy).
LPA requested the following updated documents:
- Facility sketch (LIC999) to reflect live-in staff bedroom
- Emergency Disaster Plan (LIC 610D) section 1 - Assignments During an Emergency
- Facility Mitigation Plan (LIC808) pages 8 and 14

Pre-licensing is incomplete with corrections needed

The Component III Orientation was completed during today's visit.

Once corrections are received from applicant, LPA will submit the pre-licensing application report to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1