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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804098
Report Date: 02/23/2023
Date Signed: 02/23/2023 11:11:02 AM

Document Has Been Signed on 02/23/2023 11:11 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:INFINITI CARE HOME #3FACILITY NUMBER:
486804098
ADMINISTRATOR:DEVERA, ALEHAFACILITY TYPE:
735
ADDRESS:353 ARLINGTON CIRCLETELEPHONE:
(707) 673-2078
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
02/23/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Aleha DeveraTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived announced at Infiniti Care Home #3 for the purpose of conducting a Pre-Licensing inspection. LPA was greeted at the door by Administrator, Aleha Devera, and was granted access into the facility. Facility is approved for 4 ambulatory clients which was Fire Clearance Granted on September 7, 2022 by Fairfield Fire Department. A copy of the Administrators First Aid Certificate and CPR was inspected and observed to be valid at the time of the inspection. Administrators First Aid Certificate and CPR expires on May 4, 2023. A copy of the Administrators certificate for the Administrator was inspected, observed, valid and expires July 3, 2024. (Administrator Certificate #: 6062935735)

LPA and Administrator toured the facility. Facility is a one story level home. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Auditory devices were found on the doors, inspected and operational during the inspection. Fire Extinguishers are dated for August 2022. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Hot water temperature measured at 118 degrees in 2 of 2 clients bathrooms. Hot water temperature is within acceptable range of 105-120 degrees. There was ample space for personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Clients bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. There was an ample supply of both perishable and non-perishable foods observed. A sample food was available for viewing during the Pre-Licensing inspection. Client records, personnel records, medication will be locked and inaccessible to clients in care. Toxins are kept locked in the laundry room located in the garage, and will be inaccessible to clients in care. Facility has a first aid kit which was inspected and found to be appropriate during the Pre-Licensing inspection. There is outdoor space for activities that was inspected and found to be appropriate during the Pre-Licensing inspection.

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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: INFINITI CARE HOME #3
FACILITY NUMBER: 486804098
VISIT DATE: 02/23/2023
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During the Pre-Licensing inspection, LPA discussed the infection control plan with the Administrator and advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA reviewed the Mitigation Plan with the facility during the Pre-Licensing inspection. Facility will contact Solano County Public Health. Facility is in the process of getting N95 Fit Tested.

Emergency Disaster Plan was discussed in detail with the Administrator. All staff will be trained in the Emergency Disaster and PPE training which includes donning and doffing of PPE. Emergency Generator will be brought on site prior to admitting clients. Component III was waived due to licensee already operating two other Adult Residential Facilities. Furthermore, Administrator is well versed on Adult Residential Facility specific regulations.

Exit interview was conducted, and a copy of this report was signed and given to the Administrator. LPA will forward this report to the assigned Application Analyst in our Department; The Application Analyst will notify the Applicant of the status of the application.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC809 (FAS) - (06/04)
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