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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804110
Report Date: 10/31/2022
Date Signed: 10/31/2022 11:37:27 AM

Document Has Been Signed on 10/31/2022 11:37 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: 4DATE:
10/31/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Zina LeeTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Zina's Care Home I for the purpose of conducting a Post-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.

LPA and Administrator toured the facility. 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 with all exits free from obstruction. Fire Extinguishers are dated for September 2022. All Smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the inspection. Hot water temperature measured at 111 degrees in 2 of 2 clients bathrooms. 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 Post-Licensing inspection. There is outdoor space for activities. Servicing for auditory devices will be conducted on November 9, 2022. (See LIC 9102) Facility has a first aid kit which was found to be appropriate during the inspection. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings, and client’s beds were outfitted with mattress pads as required by Title 22 Regulations.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA observed no signs on the front door or around the facility regarding COVID-19` (See LIC 9102). LPA reviewed the Mitigation Plan with the facility during the Post-Licensing inspection. Facility will contact Solano County Public Health regarding N95 Fit testing.

No deficiencies were cited during this Post-Licensing inspection. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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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