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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804235
Report Date: 07/19/2024
Date Signed: 07/19/2024 04:09:40 PM

Document Has Been Signed on 07/19/2024 04:09 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:HORIZON HOME-BAYSIDEFACILITY NUMBER:
486804235
ADMINISTRATOR/
DIRECTOR:		BURNETT, JOHNFACILITY TYPE:
735
ADDRESS:625 WHISPERING BAY LANETELEPHONE:
(415) 902-9634
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 0DATE:
07/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:51 AM
MET WITH:John Burnett & Ginger Burnett, Licensee ApplicantsTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 7/19/2024 Licensing Program Analysts (LPA's) Tobola and Loera conducted a pre-licensing inspection and was greeted by Licensee Applicants John & Ginger Burnett. This pre-licensing inspection is being conducted for an initial licensing. The facility is a two-story home with a fire Clearance has been approved for 4 ambulatory clients. Licensee Applicant is currently in partnership with North Bay Regional Center and had been approved for vendorization.

LPA's 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 purchased. Smoke detectors and carbon monoxide detectors were tested in common areas and client bedrooms all of which were found to be in working order. Emergency exits along the both side of the facility have appropriate hardware and found to be unobstructed. Water was measured between 127 & 128 degrees F in faucets used by clients which is not within regulation between 105 & 120 degrees F. Licensee Applicant agrees to submit 4-day log of water temperature for clearance.[

There was an ample supply of linens with appropriate bedding equipped in client rooms. LPA's requested for purchase of mattress padding available for each client in care. An additional supply of hygiene, continence and paper products are located in client bedrooms. Stairs and hallways are equipped with several 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. Cleaning products and other toxins and chemicals are kept out of client access and found secured in the garage and storage closet. 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 on the refrigerator 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: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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: HORIZON HOME-BAYSIDE
FACILITY NUMBER: 486804235
VISIT DATE: 07/19/2024
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Medications are centrally stored and secured in locked cabinet located in the dining area. The facility will be creating hard copy files for all client specified documents including care plans, medical reports and dietary restrictions. Licensee applicant to also ensure hard copies of appropriate staffing records, program operation documentation and emergency disaster information to be on file. Licensee Applicant indicated that they have all licensing document templates ready on file. 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 on-call direct support staff and have been informed of association process.

The backyard features a large patio with shaded seating for client outdoor use. Windows and blinds are all found to be in good repair. Emergency evacuation maps and clear exit signs are posted appropriately. Infection control plan has been updated and protocol infection prevention information to be posted at the entrance, common areas and bathrooms. Licensee is to submit photo proof of emergency disaster supplies to CCLD. The facility and facility operation plan are found to be adequate and tour of the facility completed.

Licensee will be sending a copy of the liability insurance to CCLD once completed. 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: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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