486804114-5-16-2023-21-AS-DTOA-CRVVV3-20230516164540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804114
Report Date: 05/16/2023
Date Signed: 05/16/2023 04:45:49 PM

Document Has Been Signed on 05/16/2023 04:45 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:	(650) 532-4317
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 2	DATE:	05/16/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	02:47 PM
MET WITH:	Arinzana Reyes, House Manager		TIME COMPLETED:	05:00 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	On 5/16/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced post licensing inspection for this facility and met with House Manager, Arinzana Reyes (AR). Licensee, Luningning Sikat was contacted by telephone but was unable to meet during the visit. The facility currently provides care for two (2) residents both of which with a diagnosis of dementia and both of which are receiving hospice services. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with House Manager, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 10/4/2023 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored securely in designated staff quarters and garage. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. LPA tested smoke alarms and carbon monoxide detector and were all found to be in working order. Medication is stored in a secured cabinet located in the living room closet. A spot medication count was conducted and both records and administration review found to be in order. LPA conducted a review of staff records and confirm ed that 2 out of 2 staff are in need of updating their 1st Aid & CPR certification as expired on 12/25/2022. Technical Violation issued. Licensee agrees to update staff certification by correction date 5/23/2023. Upon review of training records, LPA found that 2 out of 2 staff are in the process of completing their initial 40 hour onboard training. Technical Advisory issued. Licensee agrees to implement staff training and submit proof to CCLD of completion. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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: GOOD SAMARITAN CARE HOME	FACILITY NUMBER: 486804114
	VISIT DATE: 05/16/2023

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Upon a review of CCLD Guardian Staff Roster, LPA found that staff, (S1 & S2) are not properly associated to the facility. Licensee notified LPA that they had sent a transfer request for both S1 and S2 to be associated in March of 2023. Documentation was provided. In further review of Guardian search, LPA found that both R1 & R2 have background clearances and association to other facilities in the area. Licensee agrees to follow up with LPA and CCLD ensuring the staff are properly associated to the facility. Technical Advisory issued.

During the inspection LPA observed auditory alarm at the front door in need of repair. Licensee was notified. Technical Violation issued. Licensee agrees to replace auditory alarm and send proof of repairs to CCLD by POC date 5/17/2023.

Janolyn Rae De Guzman's Administrator Certification 6063333740 is valid through 8/5/2024.

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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