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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804064
Report Date: 06/09/2023
Date Signed: 06/09/2023 03:41:03 PM


Document Has Been Signed on 06/09/2023 03:41 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:ART OF HOMECAREFACILITY NUMBER:
486804064
ADMINISTRATOR:VILLEGAS, IMEEFACILITY TYPE:
740
ADDRESS:1060 FEATHER RIVER CTTELEPHONE:
(707) 372-1355
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY:6CENSUS: 5DATE:
06/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Imee Villegas, AdministratorTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Lead Staff, Quirino Sombito. Administrator Imee Villegas was contacted and arrived later in the visit. The facility is a single story home licensed for six non-ambulatory residents and a hospice waiver capacity of three. The facility currently provides care for five residents, one of which is on hospice and some of which with a diagnosis of dementia.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator and 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 Extinguisher was found to be last charged on 6/8/2023 at the time of visit. Smoke detectors and carbon monoxide detectors were all 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 and secured in locked cabinets in the facility kitchen, bathroom sinks and in the garage/laundry areas. There was a supply of cleaners, hygiene products and paper products available for resident use. All resident’s bedrooms have lighting, appropriate furnishings and an ample supply of clean linens. Water was measured at faucets accessible to residents and measured between 115.7 and 117.1. degrees F which is within regulation.

Residents were observed interacting with staff in the common area, or watching television in their bedrooms. Residents appear to have positive relations with staff but participate in activities individually. LPA tested resident call pendants for staff assistance which signal to the kitchen for staff to respond. There are two emergency exits located in the backyard both of which were found to be unobstructed. All auditory alarms at resident bedroom and facility exits were found to be functioning. LPA observed a separate refrigerator located in the kitchen area that stores prescribed medication. Licensee has previously purchased an attachable lock but has not yet installed. Licensee agrees to install the lock to secure medications within the day. Photo corrections to be sent to CCLD for corrections. Technical Violation issued.

Continued onto LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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: ART OF HOMECARE
FACILITY NUMBER: 486804064
VISIT DATE: 06/09/2023
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During the inspection LPA observed a camera located along the corner of resident (R1's) bedroom. LPA found that the camera was requested by R1's family and purchased by the facility Administrator. The camera is for the purpose of monitoring private caregiver assigned by the family who accompanies R1 during overnight hours. LPA and Administrator discussed the need for an exception in order to continue using the camera in R1's bedroom as it is a private space and potential violation of resident rights. Administrator agrees to review with R1's family and submit an exception letter request to CCLD along with appropriate documentation. Department to review and return at a later date.

LPA was informed that the facility is undergoing a full file organizing and has relocated the current staff and resident files at their main office. LPA will be returning to the facility for an annual continuation to complete review of all facility files, training records, medication review and for updates on the exception request regarding camera installed in resident R1's bedroom.

Administrator, Imee Villegas's Administrator Certification 6030808740 is valid through 6/9/2024.

LPA requested the following documents be sent to CCL by COB 7/9/2022:

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.
No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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