486804114-12-23-2022-21-AS-KWAS-CMDU4V-20221223141545

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804114
Report Date: 12/23/2022
Date Signed: 12/23/2022 02:18:02 PM

Document Has Been Signed on 12/23/2022 02:18 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:	GOOD SAMARITAN CARE HOME		FACILITY NUMBER:	486804114
ADMINISTRATOR:	DE GUZMAN, JANOLYN R.		FACILITY TYPE:	740
ADDRESS:	506 LABRADOR WAY		TELEPHONE:	(707) 718-0498
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 4	DATE:	12/23/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Applicant, Lunigning Sikat		TIME COMPLETED:	02:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced pre-licensing inspection on 12/23/2022. LPA met with Applicant, Lunigning Sikat, and Janolyn R. De Guzman (6063333740 exp 08/05/2024) who will be the Administrator once the facility is approved for licensure. The applicant submitted an application to change ownership to the centralized application unit. The facility is currently licensed as The Good Samaritan Care Home, 486800302. Once the change of ownership is approved, the facility will be licensed as Good Samaritan Care Home, 48604114. The facility has a fire clearance approval from the City of Suisun City Fire Department for a total capacity of 6 Non-Ambulatory residents (the facility does not have approval for bedridden). Facility will operate with 24/7 staffing (staff room available) and Licensee will ensure sufficient staffing at all times. During today’s visit LPA observed the following items: COVID-19 postings and screening station including thermometer and sign in sheet Lockable separate cabinets for toxins/cleaners, and knives. All exits were unobstructed; 1 Fire Extinguisher charged and serviced 10/04/2022 Smoke detectors and 1 carbon monoxide detector, which were tested and observed operational Complete first aid kit, night-lights leading to bathroom, and flashlight for emergency lighting Supply of linens, paper products, and hygiene supplies available Required furnishings in all resident bedrooms Required postings (Emergency plan/numbers, CCLD complaint poster, Ombudsman poster). Medication was centrally stored behind a locked closet. Continued on 809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: GOOD SAMARITAN CARE HOME	FACILITY NUMBER: 486804114
	VISIT DATE: 12/23/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The applicant will update the facility sketch to include non-ambulatory and bedridden bedrooms. LPA also learned that resident R1 had a recent change of condition which deemed them to be bedridden. Per the previous Administrator and Applicant, the FD has already approved them for a bedridden resident. The applicant will contact the fire department inspector and request that they update the fire clearance to include 2 bedridden residents.

The current facility was approved for up to (2) hospice residents, however there are currently 3 hospice residents residing in the facility. Prior to becoming licensed the applicant will apply for a hospice waiver for 3 or request a hospice exception request for an additional resident. Once ownership has transferred over, the applicant will have all responsible parties sign the new Admission agreement under this facility.

The Component III Orientation was completed; Pre-licensing is complete. LPA will submit the pre-licensing application report to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2