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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490106870
Report Date: 08/05/2021
Date Signed: 08/05/2021 02:34:13 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:ALL SEASONS RESIDENTIAL CARE HOMEFACILITY NUMBER:
490106870
ADMINISTRATOR:GEORGE AND LISA MELOFACILITY TYPE:
740
ADDRESS:5509 VOLKERTS ROADTELEPHONE:
(707) 829-8109
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:6CENSUS: 6DATE:
08/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Lisa Melo (Licensee)TIME COMPLETED:
02:55 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) Cuadra arrived unannounced to conduct an Annual Required inspection and met with staff, Tammi Marshall. Licensee, Lisa Melo was unavailable during inspection, but she was available by phone and gave authorization for staff to sign the report. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that facility has a binder inside the entrance to the facility with hand sanitizer, a thermometer, disinfectant wipes and a sign in sheet. LPA/staff observed a binder located in the entrance of the facility documenting staff, residents and visitors temperature readings. However, staff did not ask many screening questions to LPA when they arrived. During walk-through of the facility, LPA/staff observed a few Covid19 related posters provided by Kaiser encouraging staff and residents to take precautions related to Covid19 including physical social distancing. LPA provided via email Covid19 related posters including hand-washing, cough/sneeze etiquette, and physical distancing. LPA asked if 25% of staff are surveillance testing weekly and she stated they were conducting surveillance testing. Facility staff have completed PPE training but not all of staff have been N-95 Fit tested. LPA observed three residents in care watching television in the living room. Staff had masks on during this visit. Facility maintains a 30 day supply of medication. Facility has submitted and received approval for a Covid Mitigation Plan on 3/16/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE was observed in a location that is accessible to staff. Facility has a 100% vaccination rate of staff and residents are vaccinated.
LPA provided the following guidance to staff:
· Place Covid19 related posters through the facility including restrooms.
· Screening all visitors for symptoms regardless of vaccination status and document results.
· Complete N-95 Fit Testing for all staff.
· Review PINs 21-28-ASC and 21-32-ASC for new guidance regarding visitation, communal dining, etc.
No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
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 3