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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804233
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:17:56 PM

Document Has Been Signed on 06/12/2024 03:17 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:ICARE 4U LLCFACILITY NUMBER:
486804233
ADMINISTRATOR/
DIRECTOR:		BARSABAL, EMILYFACILITY TYPE:
735
ADDRESS:2934 CASCADE LANETELEPHONE:
(707) 862-4265
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
06/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:17 PM
MET WITH:Emily Barsabal, Licensee ApplicantTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 6/12/2024 Licensing Program Analyst LPA) Tobola conducted a pre-licensing inspection and was greeted by Licensee Applicant, Emily Barsabal. This pre-licensing inspection is being conducted for an initial licensing. Fire Clearance has been approved for 4 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 observed a fire extinguisher located in the kitchen and was found to be recently purchased. Smoke detectors and carbon monoxide detectors located in each common space and client bedrooms were interconnected, tested and and found to be in working order. Windows and blinds are all found to be in good repair with facility free of insects or pests. Emergency evacuation maps and clear exit signs are posted appropriately. Infection control plan has been updated and protocol infection prevention information are within facility operation binder. Emergency exits along the one side of the facility have appropriate hardware and found to be unobstructed. Water was measured at 118.1 degrees F in faucets used by clients which falls within regulation between 105 & 120 degrees F.

There was an ample supply of extra linens with appropriate bedding equipped in client rooms. An additional supply of hygiene, continence and paper products are located in a cabinet in client bathroom. LPA requested for hallway to be equipped with appropriate night lights for accessibility. Client bedrooms were inspected have appropriate furnishing and found to be in a clean and comfortable condition. 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. Cleaning products and other toxins and chemicals are kept out of client access and found secured under the kitchen sink. LPA observed adequate supply of both perishable and non-perishable food sufficient for the 4 clients in care. The facility will be conducting frequent grocery replenishment with consideration to client preferences and dietary restrictions. A sample menu has been completed and will be posted in the kitchen area to indicate a healthy and balance set of meals for clients in care. Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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: ICARE 4U LLC
FACILITY NUMBER: 486804233
VISIT DATE: 06/12/2024
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Medications will be centrally stored and secured in locked cabinets located in the kitchen. Licensee applicant has access to all appropriate medication administration documents including the Centrally Stored Medication Records and several other medication related forms and will have available prior to client admission. The facility has all appropriate public documentation and personal rights information posted in common spaces within the facility. The facility has begun the hiring process for direct support staff and have been informed of association process. The backyard features a large patio and side yard with shaded seating for client outdoor use. The facility is equipped with a sufficient amount of activity supplies but will have supply additional outdoor recreational items and modify activities for client use upon admission. Licensee agrees to implement appropriate internet access electronic device and a required telephone service
within the facility for client use.

Licensee Applicant agrees to provide proof/photos of the following corrections by POC date 6/19/2024:

- Internet access electronic Device (iPad) within facility
- Telephone services within facility
- Evacuation map posted in bedroom hallway
- Night light installed in bedroom hallway

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: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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