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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830786
Report Date: 01/23/2024
Date Signed: 01/23/2024 11:58:06 AM


Document Has Been Signed on 01/23/2024 11:58 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: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: 5DATE:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Romeo Cabe, AdministratorTIME COMPLETED:
12:15 PM
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On 1/23/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Administrator, Romeo Cabe. The facility currently provides care for 5 residents, 3 of which are receiving hospice services and some of which with a diagnosis of dementia.

LPA continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility to be last charged on 8/29/2023 at the time of visit. Both smoke detectors and carbon monoxide detectors throughout the facility were also tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate labeling.

Toxins are stored in a locked cabinet in the facility laundry room, under kitchen sink and garage all of which were secured upon inspection. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen drawer. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Water was measured at faucets accessible to residents and measured between 112.8 and 115.7 degrees F which is within regulation. During inspection LPA observed several surveillance cameras located in common areas and hallways, none of which record audio. One camera was observed to be facing a resident bedroom. LPA requested for Administrator to reposition or remove the camera as a potential personal rights risk to resident. Technical Advisory issued.

Continued onto LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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: OUR LADY OF PEACE HOME CARE
FACILITY NUMBER: 486830786
VISIT DATE: 01/23/2024
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Medications located in designated closet located in the hallway were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Resident medications are all delivered directly to the facility from the pharmacy. Residents that were awake during the inspection were observed interacting with staff in the common area, watching television for leisure. The facility also offers regular family visits and gatherings as well as encouraging residents to exercise their mobility. There is one emergency exit located in the backyard which was found to be unobstructed. All auditory alarms leading out of the facility including resident bedroom emergency exits were tested and all found to be in working order.

Residents utilizing hospital bed or bed rails were found to have appropriate medical orders on file. In addition, signage for use of oxygen were posted at each door of residents requiring the use. Staff quarters were located in the backyard and have been cleared by the fire department for staff to reside.
LPA conducted a sample file review for staff and found all staff to have appropriate annual training and 1st Aid & CPR certification on file. LPA also conducted a file review for all residents. Upon review, LPA found that all resident Needs & Service Plans and Physician's Reports to be current.

Administrator, Romeo Cabe's Administrator Certification 6026462740 is valid through 6/14/2025.

LPA requested the following documents be sent to CCL by COB 2/6/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance (may be submitted after 2/6/2024, due to renewal)
Control of Property/Rental Agreement

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC809 (FAS) - (06/04)
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