486804016-12-15-2022-21-AS-DTOA-CM5UDD-20221215142922

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804016
Report Date: 12/15/2022
Date Signed: 12/15/2022 02:29:33 PM

Document Has Been Signed on 12/15/2022 02:29 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:	HER ONLY DAUGHTER SENIOR CARE HOME		FACILITY NUMBER:	486804016
ADMINISTRATOR:	BOOKER, JANAI		FACILITY TYPE:	740
ADDRESS:	130 PURDUE DR.		TELEPHONE:	(707) 295-3290
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	5	CENSUS: 0	DATE:	12/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:57 PM
MET WITH:	Janai Booker, Administrator		TIME COMPLETED:	02:40 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	On 12/15/2022 Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Janai Booker. The facility currently has 0 residents in care. Facility is expecting to begin the admission process in January 2023. LPA arrived at the facility and continued with a tour of the with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 9/5/2022 at the time of the visit. Smoke and carbon monoxide detectors were inspected throughout the facility and found to be in working order. There is currently no food supply due to inactivity of the faciltiy. However, food will be stored properly as per regulations once admissions begin. Toxins are stored securely in designated cabinets located in the garage. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Facility has appropriate bedding and linens available for resident use. Hot water measured between 105.0 and 105.1 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by residents. LPA also conducted a spot file review for 2 out of 2 staff and found that all staff have updated 1st Aid & CPR Training on file. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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: HER ONLY DAUGHTER SENIOR CARE HOME	FACILITY NUMBER: 486804016
	VISIT DATE: 12/15/2022

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Infection Control:
Facility has submitted an infection control plan for review. Posters have been placed at the front door, and facility has a station in the staff file closet near facility entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Once in operation staff and clients are to be screened for temperature and symptoms on a daily basis.

No deficiencies cited during today's inspection.

LPA requested the following documents be sent to CCL by COB 12/29/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC809 (FAS) - (06/04)

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