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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804052
Report Date: 06/14/2022
Date Signed: 06/14/2022 11:25:34 AM

Document Has Been Signed on 06/14/2022 11:25 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:C & R CARE HOME LLCFACILITY NUMBER:
486804052
ADMINISTRATOR:BAYOT, ROBERT CHRISTIANFACILITY TYPE:
740
ADDRESS:373 HERON WAYTELEPHONE:
(510) 789-5155
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 5CENSUS: 0DATE:
06/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Robert Christian BayotTIME COMPLETED:
11:35 AM
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Licensing Program Analysts (LPA) Katrina Walters conducted a pre-licensing inspection on 06/14/2022. LPA met with Applicant, Robert Christian Bayot who will be Administrator when the facility is approved for licensure. On 3/14/22 The facility was granted a fire clearance approval from the Vacaville Fire Department for a capacity of 5 non-ambulatory residents. Facility will operate with a live-in caregiver and Licensee will ensure sufficient staffing at all times. The facility is one level with 3 bedrooms that may be used for residents, Staff room, 2 bathrooms, living room, dining room, kitchen, medication cabinet, laundry room with storage room and Garage. The applicant has a dementia care plan that has been approved.

During today’s visit LPA observed the following: The facility was clean and comfortable temperature. Upon entry there was an area in which staff will check in visitors. Hand sanitizer, a temperature gun, pulse oximeter, and additional Personal Protective Equipment were available for visitors and staff. LPA observed the following signs posted in the entry way: Residents right's to counsel, Let Us Know complaint poster, hand washing, masks required, personal rights, emergency disaster drills, staff roster, activity poster and menu. The Applicant has ordered the Ombudsman poster and will receive the poster after licensure.

LPA toured the facility with applicant and observed that all resident's rooms were furnished as required by regulation. A location has been designated for medication and sharps to be locked, and stored. Auditory alarms were on. Bathrooms were equipped with paper towels and hand soap. Grab bars and slip mats were present for residents safety. There were a supply of linens, paper products, and hygiene supplies available. Kitchen was spacious and clean, adequate supply of dishes and utensils. The refrigerator was clean, with perishable and non-perishable foods. The facility has a phone line designated for residents use.
Continued on 809 C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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: C & R CARE HOME LLC
FACILITY NUMBER: 486804052
VISIT DATE: 06/14/2022
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Continued from 809

In sinks used by residents, water temperature read at 114 & 115 F. LPA observed carbon monoxide and smoke detectors located throughout the facility, which were tested and appeared to be operational. All exits were unobstructed. First Aid kit, night-lights, and flashlights for emergency lighting were available. The fire extinguisher was charged and serviced on 08/31/2021.

LPA conducted a COMP III with applicant some of the following items were discussed: Administrator Qualifications, Reporting Requirements, Maintenance and Operation, Personal Accommodations, Criminal Background clearance, Acceptance and Retention, Restricted and Prohibited Health Care Conditions

This pre-licensing is complete. LPA will submit the pre-licensing reports to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. A copy of the report was given to the Applicant.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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