490108000-4-25-2022-21-AS-VWIS-CDTP8B-20220425110516

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 490108000
Report Date: 04/25/2022
Date Signed: 04/25/2022 11:05:26 AM

Document Has Been Signed on 04/25/2022 11:05 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:	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: 11	DATE:	04/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Nick Aquino		TIME COMPLETED:	11:15 AM

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) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and was greeted by staff. Administrator, Nick Aquino arrived later but had to leave prior to the end of the inspection and gave permission for staff to sign report. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA was screened by staff including having their temperature checked and filling out a questionnaire with standard Covid-19 symptom questions.. Visitors are screened and vaccination verification is being conducted per Provider Information Notice (PIN) 22-07-ASC. 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. LPA request that hand washing signs are put up in the client bathrooms and a visitor poster that is inside the facility is put on the front door. 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 at least once per 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. LPA discussed options with Administrator for having their staff N-95 fit tested. Facility has submitted their Covid Mitigation Plan and it has been reviewed Facility has 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: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

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: MC HUGH CARE HOME	FACILITY NUMBER: 490108000
	VISIT DATE: 04/25/2022

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Continued from LIC809

Facility has submitted and Community Care Licensing (CCL) has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced June 2021.

During inspection LPA observed that the facility is having a deck put in in the backyard and a new fence is being put up. Construction area is roped off with caution tape.

Administrator to ensure that staff receive continued training regarding Covid-19 including but not limited to infection control and PPE donning and doffing.

Administrator and LPA discussed their Emergency Disaster Plan and the new Infection Control Plan that all facilities must submit to CCL by June 30, 2022.

Administrator to submit updates of the following document by 05/25/2022:

LIC 308 Designated Administrator
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Liability Insurance

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: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC809 (FAS) - (06/04)

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