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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804008
Report Date: 04/07/2022
Date Signed: 04/07/2022 03:14:52 PM


Document Has Been Signed on 04/07/2022 03:14 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ALF SANCTUARY ADULT RESIDENTIAL CAREFACILITY NUMBER:
486804008
ADMINISTRATOR:AQUINO, MARICELFACILITY TYPE:
740
ADDRESS:521 SARAH WAYTELEPHONE:
(559) 303-7020
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:6CENSUS: 5DATE:
04/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Co-Administrator, Maria Buna TIME COMPLETED:
03:25 PM
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At approximately 1:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit and met with Administrator, Maria Buna.

LPA Felias discussed with Administrator the flooding that occurred on 3/31/2022, which damaged a portion of Room 1, a double occupancy room, and Room 1's bathroom and shower. Per review of incident report, Facility immediately called Plumber company to check damaged area and to fix shower drain. Affected areas were cleaned, disinfected, and dried.

Per conversation with Administrator, water from the washing machine backed up into the shower drain and flooded the surrounding areas. Plumber company stated that the floors will need to be opened to assess the damages and observe what repairs will be needed. Facility met with a claims adjuster on 4/5/2022 and is waiting for insurance coverage to be confirmed.
Facility has scheduled for repairs which will begin once insurance amount is confirmed. Estimated time to complete repairs is approximately 3 days. The residents that resided in the affected room will be moved to the facility's vacant single private room to be temporarily shared until repairs are complete.

LPA and Administrator discussed contacting the Fire Department to confirm if the private single room can be a shared double room. Facility to send an updated facility sketch if approved. During visit, Fire Marshal, Jose Colin, arrived to inspect the rooms and gave approval to facility to move residents to vacant room.

LPA to monitor situation closely. Facility to email LPA with updated facility sketch.

No Deficiencies cited during this visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
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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