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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800196
Report Date: 07/22/2021
Date Signed: 07/22/2021 12:10:03 PM

Document Has Been Signed on 07/22/2021 12:10 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:DORIS'S HOUSEFACILITY NUMBER:
496800196
ADMINISTRATOR:CAMILLERI,DORIS&JOEFACILITY TYPE:
735
ADDRESS:432 CRIVELLI DR.TELEPHONE:
(707) 996-0581
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY: 4CENSUS: 4DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Administrator, Joe CamilleriTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required- 1 Year inspection at approximately 11:10 AM, and met with administrator Joe Camilleri. The inspection is focused on the Infection Control procedures and practices of this facility.

At primary entrance LPA observed COVID postings and hand sanitizer which is required upon entry. LPA confirmed with administrator screening questions and temperature checks are conducted upon entry. LPA conducted walk through of the facility with administrator and observed COVID postings and hand sanitizer throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL).

Facility was a comfortable temperature and exits were free from obstructions. LPA confirmed administrator receives and reviews latest PINs as they are provided to facilities. Staff have not completed Personal Protective Equipment (PPE)/infection control training or been N95 fit tested. High touch surface areas are disinfected daily. There are currently 4 clients with 2 per bedroom. Facility has capability to isolate in a separate bedroom if necessary. LPA confirmed administrator has necessary PPE equipment and supplies to support a client in isolation.

Clients' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked garage cabinets. A 30 day supply of medications are stored in a locked cabinet, making them inaccessible to clients. The facility has a sufficient supply of Personal Protective Equipment (PPE) and hygiene supplies. Facility is conducting COVID-19 surveillance testing per CCL guidelines.

Continued on LIC 809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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: DORIS'S HOUSE
FACILITY NUMBER: 496800196
VISIT DATE: 07/22/2021
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Facility is allowing clients to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. Administrator indicated there are few visitors to the facility but designated visitation area would be outside if necessary.

Administrator and LPA discussed their Emergency Disaster Plan and confirmed it is current. Fire extinguisher was last charged in October, 2020.

LPA requested current copy of surety bond during visit.

No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC809 (FAS) - (06/04)
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