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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804110
Report Date: 09/20/2022
Date Signed: 09/20/2022 11:39:00 AM

Document Has Been Signed on 09/20/2022 11:39 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:ZINA'S CARE HOME IFACILITY NUMBER:
486804110
ADMINISTRATOR:LEE, ZINA M.FACILITY TYPE:
735
ADDRESS:3000 CHESTNUT CTTELEPHONE:
(707) 434-1117
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
09/20/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Administrator, Zina LeeTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Zina's Care Home I for the purpose of conducting a Pre-Licensing inspection due to Change of Location (CHOL). LPA was greeted at the door by Administrator, Zina Lee, and was granted access into the facility. Facility is approved for 4 ambulatory clients. Component III was waived due to licensee operating a current licensed facility.

LPA and Administrator toured the facility at 10:15 AM. Facility is a one floor building. The facility was inspected and found to be clean and in good repair at the time of the inspection. Fire Extinguishers are dated for September 2022. Smoke detectors and carbon monoxide detectors were found to be operational at the time of the inspection. Hot water temperature measured at 110 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. LPA observed no paper towels or hand soap and advised the Administrator to equip the bathrooms with paper towels and hand soap before clients reside in the facility. Resident records, personnel Records, medication will be locked on this level in separate cabinets, toxins are kept locked in a laundry room closest to the garage; facility has first aid kit which was found to be appropriate during the Pre-Licensing inspection. There is outdoor space for activities. During the Pre-Licensing inspection, LPA 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 regarding N95 Fit testing. Emergency Disaster plan was discussed with the Administrator. Portable Emergency Generator will be brought on on site before move-in of clients. A copy of the Administrators First Aid Certificate and CPR was valid and expires on December 31, 2023. All staff will be trained in the Emergency Disaster and PPE training.

Exit interview was conducted, and a copy of this report was 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: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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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