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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111817
Report Date: 09/17/2021
Date Signed: 09/17/2021 01:15:16 PM

Document Has Been Signed on 09/17/2021 01:15 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LAUGHLIN COUNTRY HOMEFACILITY NUMBER:
490111817
ADMINISTRATOR:LA DOW, JEFFFACILITY TYPE:
735
ADDRESS:2565 LAUGHLIN ROADTELEPHONE:
(707) 576-1409
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 6DATE:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee/Administrator, Jeff LaTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and met with Licensee, Jeff LaDow. The inspection is focused on the Infection Control procedures and practices of this facility.

LPA initiated an inspection of the facility around 12:35pm and observed the following: Covid-19 posters were posted throughout the facility including but not limited to hand washing and cough etiquette. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is available to clients in care. Per Licensee, they regularly discuss infection control with clients and staff. Clients are encouraged to wear masks when in the community and staff are required to wear them while in the facility. Observed staff had mask on during this visit.

LPA and Licensee discussed client activities and visitation. LPA also discussed facility vaccination percentage and their testing policy. Facility to review PIN 21-40-ASC regarding visitation, testing and vaccination verification guidance for visitors.

Caregivers have completed PPE training but has not been N-95 Fit tested. Commonly touched surfaces are disinfected twice per day.

Facility has submitted their Covid Mitigation Plan and it has been reviewed by CCL. 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 located in an area that is accessible to staff who need it. Facility maintains a 30 day supply of medication.

Licensee and LPA discussed their Emergency Disaster Plan


No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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