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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804014
Report Date: 01/31/2023
Date Signed: 02/01/2023 08:55:18 AM

Document Has Been Signed on 02/01/2023 08:55 AM - 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:ZAMORA FAMILY HOMEFACILITY NUMBER:
486804014
ADMINISTRATOR:POWELL, JENNIFERFACILITY TYPE:
735
ADDRESS:116 SUNSET AVE.TELEPHONE:
(510) 828-1019
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 3CENSUS: 0DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jennifer PowellTIME COMPLETED:
04:16 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with Jennifer Powell, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. There is currently no clients in care.
LPA toured facility and grounds with administrator and observed COVID-19 precaution signs posted in common areas to promote hand washing. Visitors will be screened for COVID-19 symptoms upon arrival to the facility. LPA went over Infection control practices: entry procedures, face coverings, daily monitoring and temperatures checked for clients and staff, and 30-day PPE supply. Facility staff will clean and disinfect the facility daily. Facility understands hand sanitizer should not be placed in the rooms of residents who lack hazard awareness and impulse control. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was submitted to the department. LPA consulted regarding facilities responsibility once they receive their first client. Fire Extinguisher was found to be last charged and serviced on 1/30/2023.

LPA requested the following updated records to be submitted to Community Care Licensing by 2/27/2023
· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan

Exit interview conducted with Jennifer Powell, No deficiencies cited during today's inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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