490108000-6-15-2021-21-AS-VWIS-C3ZN9M-20210615101601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 490108000
Report Date: 06/15/2021
Date Signed: 06/15/2021 10:17:19 AM

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:	MC HUGH CARE HOME		FACILITY NUMBER:	490108000
ADMINISTRATOR:	DIZON, TIFFANY		FACILITY TYPE:	740
ADDRESS:	1000 GORDON LANE		TELEPHONE:	(707) 545-8213
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY:	15	CENSUS: 13	DATE:	06/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Nick Aquino		TIME COMPLETED:	10:30 AM

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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and was greeted by staff. Administrator, Nick Aquino arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that facility has posters on the front door indicating that visitors are not allowed. Once inside the facility, LPA observed that facility does not have a sign-in for visitors and did not screen LPA when they came in. LPA observed that live-in staff were not wearing masks and LPA requested that staff put on masks. LPA conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed throughout the facility. Residents are encouraged to wear masks when in the community. Commonly touched surfaces are disinfected throughout the day. LPA discussed visitation with staff who stated that residents only receive visits from their case workers and there is a designated living room for visitation. Facility has a designated isolation apartment on the facility premises. Facility staff have been trained on PPE protocols but have not yet been N-95 fit tested.

Facility has submitted their Covid Mitigation Plan and LPA reviewed it during this visit 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 is in a location that is accessible to staff and additional PPE is available as needed but is stored off-site. Facility maintains a 30 day supply of medication.

Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: MC HUGH CARE HOME	FACILITY NUMBER: 490108000
	VISIT DATE: 06/15/2021

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Continued from LIC809

Facility has a 100% vaccination rate of staff and residents so is not required to surveillance test.

LPA provided the following guidance:

Review PINs 21-17-ASC and 21-17.1-ASC for new guidance regarding visitation, communal dining, ect and update visitation policy accordingly.
Screen all visitors who come to the facility and have them sign-in to ensure proper tracing
Get staff N-95 fit tested
Staff to wear masks when in general areas of the facility

Administrator and LPA discussed the Emergency Disaster Plan and LPA requested an updated Emergency Disaster Plan.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC809 (FAS) - (06/04)

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