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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111817
Report Date: 09/23/2022
Date Signed: 09/23/2022 12:46:26 PM

Document Has Been Signed on 09/23/2022 12:46 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Licensee, Jeff LaDowTIME COMPLETED:
12:56 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) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Licensee/Administrator, Jeff LaDow. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was greeted by Licensee. LPA discussed facility screening policy with Licensee who stated that facility does not really get visitors but staff do screen visitors when they come and are conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility around 11:45am and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Commonly touched surfaces are disinfected three times per day. Facility continues to screen staff and clients and maintains documentation

Facility has a designated visitation area outside and is allowing for visitation inside per CCL guidance. Staff continue to receive training on infection control and Personal Protective Equipment (PPE). LPA and Licensee discussed visitation and activities. Facility has more than a 30 day supply of PPE including but not limited to masks, gloves, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced April 2022. Smoke and carbon monoxide detectors throughout facility were tested and operational. Licensee and LPA discussed their Emergency Disaster Plan and Infection Control.

Licensee/Administrator to submit updates of the following documents by 10/23/2022:
LIC 500 Personnel Summary
LIC 9020 Register of Facility Client’s

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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 1