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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804007
Report Date: 12/05/2022
Date Signed: 12/05/2022 12:50:52 PM

Document Has Been Signed on 12/05/2022 12:50 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: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:
12/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Julie Martuscello, Administrator & LicenseeTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Julie Martuscello, Administrator & Licensee. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.
LPA toured the facility, all exits were unobstructed. Fire extinguisher was charged and serviced 04/12/2022. LPA observed a screening station complete with a sign-in sheet, COVID-19 screening questionnaire, thermometer, and hand sanitizer. The facility has an ample supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff and client's temperatures are taken daily and documented. Staff have received refresher training's on 06/10/2022 on the following: proper utilization of PPE, infection prevention & control (IPC), and environmental cleaning & disinfection to prevent COVID-19 and other infectious/communicable diseases. Staff have current CPR/first aid certifications in file. During this visit, LPA verified staff COVID-19 vaccination records. Designated staff have completed N-95 Fit Testing (Cal/OSHA requirement) and have documentation in file. LPA discussed with administrator the facility's current fire clearance (approved for 4 ambulatory only) and medication storage. All staff wore masks during this visit.
LPA requested the following updated forms to be submitted to Community Care Licensing by 01/05/2023:
    · LIC 308 Designation of Facility Responsibility (1 person per form)
    · LIC 500 Personnel Report
    · LIC 400 Affidavit Regarding Resident Cash Resources (indicate if not handling cash for residents)
    · Surety Bond
    · LIC 610D Emergency Disaster Plan
    · LIC 9020 Register of Facility Residents/clients
    · Copy of current Administrator's Certificate
    · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
    · Infection control plan
Exit interview conducted with Administrator, whose signature on this document confirms receipt.
**No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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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