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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486890081
Report Date: 02/10/2023
Date Signed: 02/10/2023 10:45:06 AM

Document Has Been Signed on 02/10/2023 10:45 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:GOOD SAMARITAN CARE HOME LLCFACILITY NUMBER:
486890081
ADMINISTRATOR:SKILLMAN, TROYFACILITY TYPE:
735
ADDRESS:364 PEPPER DRIVETELEPHONE:
(707) 643-3567
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 4DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Alice Gipson, Lead StaffTIME COMPLETED:
11:00 AM
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On 2/10/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Lead Staff, Alice Gipson. The Licensee, Troy Skillman was contacted and notified of the visit. The facility currently provides care for 4 clients all of which were attending Day Program or on outings at the time of visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Lead Staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher located in the hallway was found to be last charged on 4/26/2022 at the time of the visit. Smoke and carbon monoxide detectors were inspected and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for clients.

Toxins are stored in a locked cabinet located in the staff bedroom and laundry room and found to be secured. There was a supply of hygiene products and paper products available and kept in client individual bedrooms. Facility provides additional hygiene product to clients when requested. All client bedrooms have lighting & appropriate furnishings. Medications and facility records are stored in designated cabinets located in the staff office and found to be secured.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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: GOOD SAMARITAN CARE HOME LLC
FACILITY NUMBER: 486890081
VISIT DATE: 02/10/2023
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LPA Tobola tested water at faucet accessible to clients and measured at 110.4 degrees F which is within Title 22 Regulations between 105 and 120 degrees F. During the inspection LPA observed client bathroom sink drain to be clogged. LPA was informed that water leakage reached hallway causing flooring to slightly raise. Lead Staff stated service request was called in as of yesterday. LPA issued Technical Violation and will be requesting for proof of repairs submitted to CCLD.

Licensee, Troy Skillman's Administrator Certificate expires on 7/11/2023.

Infection Control:
Facility has completed an Infection Control Plan and submitted CCLD for review. All clients and staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and clients ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature on daily basis or based on change of condition.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 2/24/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
Copy of Surety Bond
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC809 (FAS) - (06/04)
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