486804008-9-12-2022-21-AS-FSAI-CJ7UE7-20220912153041

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804008
Report Date: 09/12/2022
Date Signed: 09/12/2022 03:30:52 PM

Document Has Been Signed on 09/12/2022 03:30 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 CARE		FACILITY NUMBER:	486804008
ADMINISTRATOR:	AQUINO, MARICEL		FACILITY TYPE:	740
ADDRESS:	521 SARAH WAY		TELEPHONE:	(559) 303-7020
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 4	DATE:	09/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Staff Members: Deo Bardon & Reyna Yu		TIME COMPLETED:	03:50 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), Farhaan Sarangi arrived unannounced at Alf Sanctuary Adult Residential Care for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Caregiver, Deo Bardon, and was granted access into the facility. LPA and Staff Member, Reyna Yu toured the facility and found the facility to be clean and well organized. Grounds free of any apparent hazards. All exits unobstructed. Hot water temperature measured at 116 F degrees in bathrooms. Fire extinguishers was dated for September 2021. Smoke and Carbon Monoxide detectors were tested on September 24, 2021 with a passing result. Disinfectants and medications locked and stored away. First Aid kit was found to be appropriate during the inspection. Fresh and non-perishable food in adequate supply. No bodies of water on premises. No firearms stored at facility during the inspection. Sufficient linens and bedding for the residents were observed. Bathrooms clean and adequately stocked. Medications were stored and inaccessible to residents according to regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the inspection. Dangerous items were stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available. All residents bedrooms have lighting & appropriate furnishings, and facility has mattress pads available for residents as required by Title 22 Regulations. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has sufficient PPE stored underneath the credenza in the kitchen/dining room. Facility is in the process of being N95 Fit tested for staff members (See LIC 9102). LPA requested the following documents: (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

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: ALF SANCTUARY ADULT RESIDENTIAL CARE	FACILITY NUMBER: 486804008
	VISIT DATE: 09/12/2022

NARRATIVE

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LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Last Disaster Drill conducted
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents

LPA was made aware of an Administrator change during the Required-1 year inspection. LPA requested the following documents to be sent to his attention:

LIC 308 Designation of Facility responsibility (designation of who is the administrator)
Administrator Certificate
First Aid Certificate
Administrator Resume (in small facilities if possible)
LIC 500 Personnel Report
LIC 501 Personnel Record
LIC 503 Health Screening Report - personnel (keep on facility staff file to be reviewed)
TB test that shows "negative" (keep on facility staff file to be reviewed)
LIC 508 Criminal Record Statement
LIC 9182 Criminal Record Exemption Transfer Request
Copy of Personal ID

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was given to the facility Staff Member, Reyna Yu

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC809 (FAS) - (06/04)

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