486804052-7-27-2023-21-AS-DTOA-CU5VLF-20230727163151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804052
Report Date: 07/27/2023
Date Signed: 07/27/2023 04:31:55 PM

Document Has Been Signed on 07/27/2023 04:31 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:	C & R CARE HOME LLC		FACILITY NUMBER:	486804052
ADMINISTRATOR:	BAYOT, ROBERT CHRISTIAN		FACILITY TYPE:	740
ADDRESS:	373 HERON WAY		TELEPHONE:	(510) 789-5155
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95688
CAPACITY:	5	CENSUS: 3	DATE:	07/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Salome Magno, Caregiver Staff		TIME COMPLETED:	04:45 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 7/27/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Caregiver Staff, Salome Magno and Andrew Baybay. Administrator, Robert Bayot was contacted but was unable to meet at the time of visit. The facility is a single story home licensed for five non-ambulatory residents and a hospice waiver capacity of 5. The facility currently provides care for 3 residents, some of which with a diagnosis of dementia and 2 of which are receiving hospice services. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with caregiver staff, 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 8/16/2022 at the time of visit. Both smoke detectors and carbon monoxide detectors throughout the facility are interconnected, tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet near the facility laundry room. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen pantry. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Water was measured at faucets accessible to residents and measured at 113.1 degrees F which is within regulation. 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: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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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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: 07/27/2023

NARRATIVE

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Medications located in designated cabinet were found to be secured. LPA conducted a spot check of medications and found to be in order. Facility receives medication deliveries direct from pharmacy. Resident were observed interacting with staff in the common area, or watching television for leisure. There are two emergency exits located in the backyard both of which were found to be unobstructed. All auditory alarms leading out of the facility send a chime to the front room and were all found to be in working order.

LPA conducted a sample file review for staff and found all staff to have updated 1st Aid & CPR certification on file. Staff S1 was recently hired and will require additional onboard training to be completed, Technical Advisory issued. LPA also conducted a file review for all residents. Upon review LPA found that resident R1 was recently admitted an requires signatures from conservator. LPA observed note indicators on C1's file of Administrator acknowledging signatures needed. Technical Advisory issued.

Administrator, 's Administrator Certification 60613332740 is valid through 11/5/2023.

LPA requested the following documents be sent to CCL by COB 8/27/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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