486804168-9-26-2023-21-AS-JNAA-CW2Q2Y-20230926114755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804168
Report Date: 09/26/2023
Date Signed: 09/26/2023 11:48:00 AM

Document Has Been Signed on 09/26/2023 11:48 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:	SPECIAL CARE 4		FACILITY NUMBER:	486804168
ADMINISTRATOR:	AUJLA, MANJINDER		FACILITY TYPE:	735
ADDRESS:	1017 PINTAIL DRIVE		TELEPHONE:	(707) 981-1987
CITY:	SUISUN	STATE: CA	ZIP CODE:	94585
CAPACITY: 4		CENSUS: 0	DATE:	09/26/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Manjinder Aujla,Administrator		TIME COMPLETED:	11:47 AM

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) Jill Nakagawa conducted a pre-licensing inspection on 09/26/2023. LPA met with Applicant, Manjinder Aujla (6061701735 exp 11/19/2023), who will be the Administrator when the facility is licensed. Once licensed this facility will operate as an Adult Residential Facility that serves individuals with intellectual disabilities. This facility is vendored with North Bay Regional Center. On 07/11/2023 the facility was granted a fire clearance approval from the City of Suisun Fire Department for a capacity of 4 Ambulatory clients. The facility is one-story with 4 bedrooms for client usage, 2 bathrooms, garage, living room, dining room, office, kitchen, activity room, and laundry room. There is also a separate staff room. There is a nice backyard for outdoor activities, including shade and seating. LPA and applicant toured the facility to ensure health and safety and made the following observations: Upon entry there is a screening station/log-in center for visitors that included a thermometer and a sign in sheet. Required signs were posted. Smoke and carbon monoxide detectors were tested and appeared to be operational. The fire extinguisher was fully charged and dated June 27, 2023. All exits were unobstructed. The applicant submitted an emergency disaster plan that has been approved. The applicant has designated at least two emergency disaster locations Continued.......

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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: SPECIAL CARE 4	FACILITY NUMBER: 486804168
	VISIT DATE: 09/26/2023

NARRATIVE

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First aid kit had all components required per regulation. Emergency lighting was available in the hallways. Bedrooms were furnished with chairs, dressers, beds with padding and appropriate lighting. Bathrooms had hand washing supplies and paper products were available. Water temperature in faucets used by residents measured at 113 F. There was an ample supply of linens, dishes and cooking supplies. There was a sufficient amount of cleaning supplies which were locked and inaccessible to residents. There was an ample supply of hygiene products available. LPA observed adequate emergency food and water supply Medication will be locked in cabinet in kitchen area. It will also store the facility records.

LPA conducted a COMP III with applicant. Some of the following items were discussed: Reporting Requirements, Maintenance and Operation, Personal Accommodations, Criminal Background clearance, Acceptance and Retention, Guardian, Restricted and Prohibited Health Care Conditions.

Liability insurance has been arranged and is currently in underwriting; awaiting final approval of license.

LPA found no areas of concern. Applicant is well-organized and educated about running a facility.

This pre-licensing is complete. LPA will submit the pre-licensing reports to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. A copy of the report was given to the Applicant.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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