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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830735
Report Date: 12/21/2021
Date Signed: 12/21/2021 01:54:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:VACA VALLEY LIVING A MEMORY CARE COMMUNITYFACILITY NUMBER:
486830735
ADMINISTRATOR:JAMIE HEALERFACILITY TYPE:
740
ADDRESS:80 ORANGE TREE CIRCLETELEPHONE:
(707) 724-6751
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:60CENSUS: DATE:
12/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator, Jaime HealerTIME COMPLETED:
02:05 PM
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At approximately 11:25 AM, Licensing Program Analyst (LPA) Katrina Walters arrived at this facility unannounced, to conduct an Annual Required infection control inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPA met with Administrator, Jaime Healer. This facility has submitted a COVID-19 Mitigation plan that was reviewed and approved my Community Care Licensing on 7/20/21.

Upon arrival to the facility, Staff (S1) checked LPAs temperature and asked COVID-19 screening questions. The facilities visitor policy was posted on entrance doors. In addition, signs to promote social distancing and the spread of COVID-19 were posted at the entrance and throughout the facility. One central entry point has been designated for staff and visitors. All staff were wearing mask. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident bedrooms, common areas, laundry room, break room, dinning areas were inspected.

Resident's are encouraged to wear mask, as much as practically possible given their health condition. LPA advised that resident's wear face mask when in close contact with facility staff and outside persons. Facility has procedures for testing and isolating all individuals who are showing symptoms. Facility keeps track of all resident, staff and visitors vaccination records in their appropriate binders. Facility has a 30 day supply of Personal Protective Equipment (PPE) and incontinence product supply. All staff have been fit tested for N95 mask, and have received training on COVID-19 exposure.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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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