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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804080
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:22:14 PM

Document Has Been Signed on 08/26/2022 12:22 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:DANLE'S CARE HOME IIIFACILITY NUMBER:
486804080
ADMINISTRATOR:DANLE, SINNINFACILITY TYPE:
735
ADDRESS:811 WHITE WING LANETELEPHONE:
(707) 759-2028
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 6CENSUS: 0DATE:
08/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sinnin DanleTIME COMPLETED:
12:39 PM
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Licensing Program Analyst (LPA) Katrina Walters conducted a pre-licensing inspection on 08/26/2022. LPA met with Applicant, Sinnin Danle (60102447735 exp 2/24/24), who will be the Administrator when the facility is licensed . On 8/01/22 the facility was granted a fire clearance approval from the Suisun City Fire Department for a capacity of 4 Ambulatory clients. Facility will operate with live-in staff, and ensure sufficient staffing at all times.

The facility is two stories with 3 bedrooms for client usage, 1 staff room, 2.5 bathrooms, garage, living room, dining room, office, kitchen, medication cabinet, and laundry room. Per the fire department, the garage is excluded from being a living space.

At approximately 10:30 am LPA and applicant toured the facility to ensure that COVID-19 protocols were in place and made the following observations: At the entrance there was hand sanitizer, a wall thermometer, oxygen meter, disposable mask and N95's to assess visitors. Signs were posted to encourage droplet precaution throughout the facility and at the entrance. Facility has at least a 30 day supply of personal protective equipment. In the event that a client needs to quarantine, they're able to quarantine in the prospective bedrooms.

LPA toured the facility for environmental and physical plant safety and found that the facility was clean an comfortable temperature. Smoke and carbon monoxide detectors were tested and appeared to be operational. The fire extinguisher was last serviced 10/18/21. All exits were unobstructed. The applicant submitted an emergency disaster plan that has been approved. The applicant has designated at least two emergency disaster location.

Continued onto 809 C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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: DANLE'S CARE HOME III
FACILITY NUMBER: 486804080
VISIT DATE: 08/26/2022
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Continued from 809

First Aid kit had all components required per regulation. Emergency lighting was available in all client rooms and in the hallways. Bedrooms were furnished with chairs, dressers, beds with padding and appropriate lighting. Bathroom's had hand washing supplies and paper products were available. Water temperature in faucets used by residents measured at 109.1 & 115. 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 emergency food and water supply. Toxins will be secured 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. Medication will be locked in a file cabinet.

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. Applicant will update their facility sketch to designate the staff room and send copy to the Suisun City Fire Department and the applicant unit.

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: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC809 (FAS) - (06/04)
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