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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804093
Report Date: 12/09/2022
Date Signed: 12/09/2022 01:23:00 PM

Document Has Been Signed on 12/09/2022 01:23 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:SPECIAL CARE 3FACILITY NUMBER:
486804093
ADMINISTRATOR:AUJLA, HARJITFACILITY TYPE:
735
ADDRESS:1753 VENTURA WAYTELEPHONE:
(707) 580-5990
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 3DATE:
12/09/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:Harjit AujlaTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Katrina Walters arrived unannounced to conduct a Post Licensing inspection and met with Licensee, Harjit Aujla. The inspection is focused on the Infection Control procedures and practices of this facility. At the time of inspection there were two clients away at day program. One client was at the facility with one staff. The licensee/administrator and another staff arrived later.

Once inside, LPA observed a screening station near the entrance that included a visitor sign in along with temperature gun. Staff checked LPA temperature. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that promoted droplet precaution. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Commonly touched surfaces are disinfected on each shift. Facility maintains documentation of client's daily temperatures. Bathrooms were stocked with paper towel and paper products.

Facility has at least a 30 day supply of Incontinence, medication and personal protective equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Smoke and carbon monoxide detectors were tested and appeared to be working. Fire extinguisher was last serviced 07/22/2022. LPA reviewed C1's Needs and Service Plan to ensure facility has plan in place for R1's restricted health condition.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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