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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804072
Report Date: 06/21/2022
Date Signed: 06/21/2022 02:35:11 PM


Document Has Been Signed on 06/21/2022 02:35 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:AAA RESIDENTIAL CARE HOMEFACILITY NUMBER:
486804072
ADMINISTRATOR:ANTONIO, ANNABELLEFACILITY TYPE:
740
ADDRESS:147 COLUMBIA WAYTELEPHONE:
(510) 685-4280
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 0DATE:
06/21/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Alicia Poquiz, Licensee ApplicantTIME COMPLETED:
02:45 PM
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Licensing Program Analyst's (LPA) Tobola conducted a pre-licensing inspection and was greeted by Licensee, Alicia Poquiz and Administrator, Annabelle Antonio. This pre-licensing inspection is being conducted as an initial facility application. Fire Clearance has been approved for 4 ambulatory and 2 non-ambulatory residents. There are currently 0 residents in care.

LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Fire extinguisher was charged and current. Smoke detectors and carbon monoxide detectors were present and all functional. Exits were observed to be unobstructed. Hot water measured between 112.2 & 113.0 degrees in faucets used by residents which falls within regulation between 105 & 120 degrees F. There was an ample supply of linens, dishes and cooking supplies. There was a sufficient supply of cleaning supplies and hygiene products available for residents. LPA observed adequate food supply per facility capacity. Facility was found to be a comfortable temperature of 74 degrees F. Toxins were observed to be secured located in the garage and under the kitchen sink. In addition, all knives and other sharp items were found to be in a locked location in the kitchen.

Medications are centrally stored in a locked closet in the hallway along with medication records. Facility also has blank templates for incoming resident and staff records, all contained in a secured location.
Required postings such as Rights to resident councils, client's rights and Complaint Poster are posted at the main entrance of the facility.

In addition, LPA observed staff living quarters located on the facility side yard. Facility sketch does not indicate staff living quarters however Licensee Applicant stated Fire Inspector is aware and has inspected the room. LPA is requesting for Licensee Applicant to update facility sketch and resubmit fire clearance inspection request for final approval by Plan of Correction date 6/24/2022. Licensee Applicant is to provide CCL with updated Fire Clearance once completed.

Continued onto LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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: AAA RESIDENTIAL CARE HOME
FACILITY NUMBER: 486804072
VISIT DATE: 06/21/2022
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Component III orientation was conducted with the Licensee Applicant.

The pre-licensing evaluation has been completed. License will be granted upon completion of fire re-inspection visit and a final review and approval from the Licensing Program Manager.

This report was reviewed with applicant and an electronic copy was provided. Signatures on file.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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