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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804093
Report Date: 08/26/2022
Date Signed: 08/26/2022 09:46:11 AM

Document Has Been Signed on 08/26/2022 09:46 AM - 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:SPECIAL CARE 3FACILITY NUMBER:
486804093
ADMINISTRATOR:AUJLA, HARJITFACILITY TYPE:
735
ADDRESS:1753 VENTURA WAYTELEPHONE:
(707) 580-5990
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 0DATE:
08/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Harjit AujlaTIME COMPLETED:
09:55 AM
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Licensing Program Analysts (LPA) Katrina Walters conducted a pre-licensing inspection on 08/26/2022. LPA met with Applicant, Harjit Aujla, who will be the Administrator when the facility is licensed. On 8/02/22 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 one level with 3 bedrooms that may be used for clients, staff room, 2 bathrooms, garage dwelling room, living room, dining room, extra room, kitchen, medication cabinet, and laundry room. Per the fire department, the garage modification unit should not be used for client use.

LPA toured the facility to ensure that COVID-19 protocols were in place and made the following observations: At the entrance of the facility, a sign in sheet/binder was placed on the entry table for all visitors to sign-in and be screened. There was hand sanitizer and disposable mask and N95's available for visitors. Signs were posted to encourage droplet precaution. In the extra room, there are emergency quarantine bins for clients and staff, which include personal protective equipment in the event that a client must isolate, or a staff need to engage with a COVID positive client.

Continued on 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: SPECIAL CARE 3
FACILITY NUMBER: 486804093
VISIT DATE: 08/26/2022
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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 7/22/22. The applicant will ensure that all exits are unobstructed. In the event that a client has a wandering behavior, the applicant will use auditory alarms. First Aid kit had all components required per regulation. Emergency lighting was available in all client rooms. 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 114.

LPA reviewed records which included: Administrator certificate, duties and qualifications, infection control plan, program plan, sample activity calendar and menu. A space has been designated to ensure confidentially and store facility files. Staff binders were found to be organized. The applicant submitted an emergency disaster plan that has been approved. Facility has submitted a request for liability insurance quotes and will ensure that that they send LPA copy of liability insurance once the facility is licensed.

The following signs were posted in the entry way: Let Us Know complaint poster, rights of individuals with disabilities, house rules and emergency disaster information.

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.

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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