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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804134
Report Date: 05/04/2023
Date Signed: 05/04/2023 01:45:47 PM

Document Has Been Signed on 05/04/2023 01:45 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:GANNET PRIME CAREFACILITY NUMBER:
486804134
ADMINISTRATOR:ACOSTA, GRACE R.FACILITY TYPE:
735
ADDRESS:1133 GANNET CTTELEPHONE:
(510) 329-5921
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 0DATE:
05/04/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Licensee, Grace Acosta
Prospective Administrator, Maria Batungbakal		TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived announced at Gannet Prime Care for the purpose of conducting a Pre-Licensing inspection. LPA was greeted at the door by Licensee, Grace Acosta and Prospective Administrator, Maria Batungbakal. The Fire Clearance was granted for 6 Ambulatory clients with 0 Non-Ambulatory and 0 Bedridden clients. Administrators Certificate (Administrator Certificate #: 6066010735 was issued on 03/30/2023 with an expiration 03/29/2025) was reviewed by the LPA during the Pre-Licensing Inspection and found to be valid and appropriate. A copy of the Administrators First Aid Certificate and CPR was valid and expires on November 2024.

LPA, Licensee and Prospective Administrator toured the facility. LPA observed the facility to be clean, safe and sanitary with all exits free from obstruction. Fire Extinguishers was most recently purchased and observed to be brand new during the Pre-Licensing inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the Pre-Licensing 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. Client records, personnel Records, medication will be locked and in separate cabinets, toxins are kept locked and 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 an outdoor space for activities with a shaded area. 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. Emergency Disaster plan was discussed with the Administrator. All staff will be trained in the Emergency Disaster and PPE training. LPA was made aware that the facility is Solar Powered with a back up battery panel observed in front of the house.

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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: GANNET PRIME CARE
FACILITY NUMBER: 486804134
VISIT DATE: 05/04/2023
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LPA was made aware that the Licensee also operates another Adult Residential Facility in another County. Component III was waived.

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: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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