<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486890050
Report Date: 05/12/2022
Date Signed: 05/19/2022 02:07:23 PM

Document Has Been Signed on 05/19/2022 02:07 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:NATIONAL VALLEJOFACILITY NUMBER:
486890050
ADMINISTRATOR:MARRAMA, DEBRAFACILITY TYPE:
772
ADDRESS:3467 EDGEWATER PLACETELEPHONE:
(408) 688-4737
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Debra MarramaTIME COMPLETED:
12:16 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with Debra Marrama, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Facility. There is currently 4 clients in care.

LPA toured facility and grounds with Program Manager, Jose Mata and observed COVID-19 precaution signs posted in common areas to promote hand washing, mouth covering and cough etiquette. Visitors are screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for clients and staff, and 30-day PPE supply. Facility follows indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Facility understands hand sanitizer should not be placed in the rooms of residents who lack hazard awareness and impulse control. Covid-19 Mitigation plan was reviewed by the department on 6/24/2021. Staff has completed PPE training and have been N-95 Fit tested.

In addition, facility was found to be clean, at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged and serviced on August 16, 2021.

LPA conducted a previous inspection on 3/18/2022, in which the facility was found to be following infection control procedures; no hazards were observed, the facility was well organized, clean, at a comfortable temperature. Due to technical issues, LPA returned to finalize the required 1 year inspection.

Exit interview conducted with Debra Marrama
No deficiencies cited during today's inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1