486804211-5-9-2024-21-AS-DTOA-D54PXT-20240509114251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804211
Report Date: 05/09/2024
Date Signed: 05/09/2024 11:43:00 AM

Document Has Been Signed on 05/09/2024 11:43 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:	CARLSON HOME		FACILITY NUMBER:	486804211
ADMINISTRATOR/ DIRECTOR:	GERMAN, NINA		FACILITY TYPE:	735
ADDRESS:	5287 CARLSON LANE		TELEPHONE:	(650) 745-5080
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 4		CENSUS: 0	DATE:	05/09/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:42 AM
MET WITH:	Licensee Applicant, Jethro Nicolas		TIME VISIT/ INSPECTION COMPLETED:	12:00 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 5/9/2024 Licensing Program Analysts LPA's) Tobola and Florio conducted a pre-licensing inspection and was greeted by Licensee Applicant, Nina German & Jethro Nicolas. This pre-licensing inspection is being conducted for an initial licensing. Fire Clearance has been approved for 4 non-ambulatory clients. Licensee Applicant is currently in partnership with North Bay Regional Center and in the process of starting vendorizing for client placement upon issue of license. LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean and comfortable temperature with bedroom doors free from obstruction. LPA's observed Fire extinguishers throughout the facility were found to be recently serviced on 2/28/2024. Smoke detectors and carbon monoxide detectors were tested in common areas and client bedrooms all of which were found to be interconnected, tested and in working order. Emergency exits along the one side of the facility have appropriate hardware and found to be unobstructed. Water was measured between 113.5 & 115.1 degrees F in faucets used by clients which falls within regulation between 105 & 120 degrees F. There was an ample supply of linens with appropriate bedding equipped in client rooms. An additional supply of hygiene, continence and paper products are located in a secured cabinet in client bathroom. Hallways are equipped with night lights for accessibility and client bedrooms have appropriate furnishings. There is a sufficient amount of dishes and cooking supplies for client use with sharps and other hazardous items kept secured in various designated drawer and cabinets as well as under the kitchen sink. Cleaning products and other toxins and chemicals are kept out of client access and found secured in the garage and kitchen area. LPA's observed adequate supply of both perishable and non-perishable food sufficient for the 4 clients in care. The facility will be conducting weekly grocery replenishment with consideration to client preferences and dietary restrictions. A sample menu will be posted in common area to indicate a healthy and balance set of meals for clients in care. The facility has a working phone landline on site with internet services for client use. Licensee applicant also purchased internet accessible electronic device for client use during the visit with receipts provided. Continued onto LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CARLSON HOME	FACILITY NUMBER: 486804211
	VISIT DATE: 05/09/2024

NARRATIVE

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Medications are centrally stored and secured in a designated medication cart located by the kitchen with Centrally Stored Medication Records and several other medication related forms on file. Licensee applicant has posted hard copies of appropriate staffing records, program operation documentation and emergency disaster information on site. The facility has all appropriate public documentation and personal rights information posted in common spaces and hallways within the facility. The facility has begun the hiring process for direct support staff and have been informed of association and staff transfer process.

The backyard features a large patio with shaded seating for client outdoor use. The facility will acquire additional recreational items for client use upon admission. Windows and blinds are all found to be in good repair. Emergency evacuation maps and clear exit signs are posted appropriately. The facility is equipped with a 3 day emergency supply for each client but will be purchasing additional emergency disaster supplies to meet requirements. There is one facility van utilized for client transportation and found to be equipped with a fire extinguisher. Licensee applicant to purchase additional first aid kit for facility vehicle. During inspection LPA's observed front entrance of the facility to be equipped with staircase. LPA's contacted Fairfield Fire Marshal for confirmation on fire clearance and appropriate emergency exits for non-ambulatory clients and will follow up at later time. LPA's did observe additional emergency exits located in client bedroom and backyard sliding door to have appropriate ramps installed. Infection control plan has been updated and protocol infection prevention information to be posted at the entrance, common areas and bathrooms. A sign in sheet with proper screening devices and protection equipment were also observed at the front entrance. The facility and facility operation plan are found to be adequate and tour of the facility completed.

The Licensee Applicant agrees to submit corrections for the following items:
- Additional emergency disaster supply
- First Aid kit for facility vehicle
- Fire clearance confirmation (entrance staircase)

Component III orientation was conducted with the Licensee Applicant. The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager. This report was reviewed with applicant and a copy was provided to the Licensee.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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