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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804134
Report Date: 05/21/2024
Date Signed: 05/21/2024 03:05:02 PM

Document Has Been Signed on 05/21/2024 03:05 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:GANNET PRIME CAREFACILITY NUMBER:
486804134
ADMINISTRATOR/
DIRECTOR:		ACOSTA, GRACE R.FACILITY TYPE:
735
ADDRESS:1133 GANNET CTTELEPHONE:
(510) 329-5921
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 0DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Grace Acosta and Maria Cielo Batugbakal, AdministratorsTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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At approximately 1:20 PM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced Annual Required inspection to this facility and was greeted by Administrators Grace Acosta and Maria Cielo Batugbaka. At approximately 1:30 PM, LPA and Administrator/Licensees toured the building and grounds which was found to be clean and in good repair. LPA advised Administrators facility must be free of debris including backyard and free of clutter throughout the facility including the garage. Administrator agreed to remove all debris and clutter prior to admitting clients moving into the facility. LPA observed all walkways and exits to be unobstructed. LPA advised Administrators prior to admitting clients must have a supply of staple nonperishable for a minimum of one week and perishable items for two days. Toxins are secure and not accessible to clients. Medication will b centrally stored and secure in a cabinet. There is a sufficient supply of linens on hand for client use.

No clients admitted at this time North Bay Regional has just approved facility for client placement. No current personnel files to be reviewed. LPA advised administrators night lights shall be maintained in hallways and non-private bathrooms. Three out of three water faucets were inspected and found to be within regulation. Water temperature measured within regulation between 118.3 and 120 degrees F at faucets accessible to clients.

Seven out of seven smoke detectors and one out of one carbon monoxide detector were inspected and found to to be in working order. One out of one fire extinguisher was fully charged. LPA advised administrators Emergency and Disaster Plan needs to be updated with non-local evacuation site.

Administrator's Certificate is expired as of 4/10/2024. LPA advised Administrator to provide proof of recertification submission.

Continued on 809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GANNET PRIME CARE
FACILITY NUMBER: 486804134
VISIT DATE: 05/21/2024
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Continued from 809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:


Rental/Lease Agreement
LIC308- Designation of Responsibility
LIC610D- Disaster Plan
Infection Control Plan as per 82095.5 (b) Infection Control Requirements
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC809 (FAS) - (06/04)
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