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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804052
Report Date: 11/03/2022
Date Signed: 11/03/2022 02:02:26 PM

Document Has Been Signed on 11/03/2022 02:02 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 LLCFACILITY NUMBER:
486804052
ADMINISTRATOR:BAYOT, ROBERT CHRISTIANFACILITY TYPE:
740
ADDRESS:373 HERON WAYTELEPHONE:
(510) 789-5155
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 5CENSUS: 1DATE:
11/03/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Jerson ValdezTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Katrina Walters arrived for the purpose of a Post-Licensing inspection and met with Staff, Jerson Valdez. The Administrator, Robert Christian Bayot arrived later. At the time of the inspection there was 1 staff providing care and supervision for 1 client . The facility operates 24 hours with live-in staff.

LPA conducted a tour with staff and made the following observations:
· COVID-19 screening station with visitor log, thermometer, hand sanitizer and face masks.
· Lockable separate cabinets for medications, toxins/cleaners, and knives.
· All exits were unobstructed
· 6 Smoke detectors and carbon monoxide detectors, which were tested & observed operational
· Night-lights, and flashlights for emergency lighting
· Supply of paper products and hand soap available
· Grab bars in the bathroom and non-slip mat in shower.
· Auditory devices observed
· Fire Extinguisher charged and serviced 08/16/2022
· Administrator Certification (expires 11/5/2023); Required postings (Personal Rights, Emergency plan/numbers, CCLD "Let Us Know" complaint poster, Emergency Disaster Plan, Resident personal rights.
Continued on 809 C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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: C & R CARE HOME LLC
FACILITY NUMBER: 486804052
VISIT DATE: 11/03/2022
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Continued from 809

At approximately 1: 00 PM a file review was conducted. The file review revealed that all staff were associated to the facility and had fingerprint clearance. Additionally all staff present had First Aid and CPR training. In review LPA learned that staff S1 and S2 did not have the training that is required per regulation. Administrator to update facility staff records and send LPA a copy of the training's.

A technical violation was issued today in regards to staff training Administrator to make corrections and send proof to LPA by 11/18/22. No deficiencies cited.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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