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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830786
Report Date: 12/21/2021
Date Signed: 12/21/2021 10:52:56 AM

Document Has Been Signed on 12/21/2021 10:52 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:OUR LADY OF PEACE HOME CAREFACILITY NUMBER:
486830786
ADMINISTRATOR:CABE, ROMEOFACILITY TYPE:
740
ADDRESS:900 DAWNVIEW WAYTELEPHONE:
(707) 447-1920
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 6DATE:
12/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Romeo CabeTIME COMPLETED:
11:02 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and met with Administrator, Romeo Cabe. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that the facility had Covid-19 posters on the front door and a sanitation station. Sign directed visitors to sanitize prior to coming into the facility and notified them that they would need to provide proof of vaccination per Provider Information Notice (PIN) 21-40-ASC. Once inside, LPA was screened by the Administrator who checked LPA's temperature and requested that LPA complete a questionnaire with standard Covid-19 symptoms. LPA conducted a walk-through of the facility and observed Covid-19 signs and hand sanitizer throughout. Hand sanitizer was also located in resident rooms. Facility has six hospice residents who are assisted with hand washing by staff but LPA suggested that Administrator still post hand washing signs in the bathrooms. Per Administrator, staff are screened at the beginning of their shift and residents are screened twice per day. Documentation is maintained. Per Administrator, they regularly discuss infection control with residents and staff. Staff are required to wear masks while in the facility and LPA observed staff with masks on during this visit. Commonly touched surfaces are disinfected at least once per day, and after facility has had a visitor. LPA confirmed that facility is following the staff vaccination guidance per PIN 21-44-ASC. Administrator has been requested to review PIN 21-49-ASC regarding updated guidance on communal dining, group activities, entertainment, non-essential services, and transportation.
Facility has a designated visitation area outside and is allowing for inside visitation after vaccination verification or proof of a negative test within 72 hours, per current CCL guidance. Visitors are required to wear a mask while in the facility. Facility has submitted their Covid Mitigation Plan and it has been reviewed by CCL. Facility has a 30 day supply of Personal Protective Equipment (PPE) . Facility maintains a 30 day supply of medication. Caregivers have completed PPE training but have not been N-95 Fit tested. LPA and Administrator discussed fit testing options.
Administrator and LPA discussed their Emergency Disaster Plan. Fire extinguishers were last serviced 8/2021. Three fire alarms and Carbon Monoxide detector were tested and operational at time of inspection.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
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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