496800937-10-14-2021-21-AS-MCUA-C7ST25-20211014142009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800937
Report Date: 10/14/2021
Date Signed: 10/14/2021 02:20:34 PM

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:	SARAH'S SENIOR RESIDENTIAL CARE		FACILITY NUMBER:	496800937
ADMINISTRATOR:	ARAYA, SARAH		FACILITY TYPE:	740
ADDRESS:	1601 CLOVER DRIVE		TELEPHONE:	(707) 542-4082
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95401
CAPACITY:	6	CENSUS: 4	DATE:	10/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:44 PM
MET WITH:	Sarah Araya (Administrator)		TIME COMPLETED:	02:25 PM

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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection and a case management to this facility. During today's visit LPA met with Administrator, Sarah Araya. LPA conducted a Risk Assessment call with Administrator prior to the visit.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility has posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit.

LPA/Administrator 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 is kept in the common area of the facility but not throughout due to safety concerns. Facility has multiple bathrooms that are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least three times a day. Facility has designated an outdoor area for visitation. Facility has a single room for each resident that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and all staff have been N-95 fit tested. Staff and residents are being monitored daily and results are documented in a binder for each month. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate of staff and residents. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. Three residents attend to day program three times a week and the other resident attends daily to day program, facility also provides activities for residents when they are at home. Residents have access to alternative communications as phone calls and video calls with their families.

Facility has submitted their Covid Mitigation Plan and approved on 4/29/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields, gowns and hand sanitizer. PPE supplies are located in an accessible place for all staff.

Continues on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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: SARAH'S SENIOR RESIDENTIAL CARE	FACILITY NUMBER: 496800937
	VISIT DATE: 10/14/2021

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Continued from LIC809...

During today's visit, LPA followed up on an incident report received on 9/10/21 regarding resident (R1) who on 9/8/21 around 12pm while attending to day program tripped and fell during lunch. Administrator was notified, day program staff contacted 911 and R1 was transported to Kaiser emergency room for further evaluation. Administrator went to Kaiser and notified responsible parties of the incident. Facility provided R1's discharge documents were it is indicating that R1 has to use a wheelchair temporarily due to a lower extremity contusion of their right leg and no broken bones. Medications were prescribed as PRN Ibuprofen 600mg every six hours as needed for pain and r1 has a doctor follow up appointment in the next 2 weeks. Per Administrator, R1 is receiving physical therapy twice per week and staying home due to day program doesn't have enough staffing to assist resident with their needs due to their mobility.

Administrator provided the following documents: Designation of Responsibility (LIC308), Affidavit regarding client cash resources (LIC400), Surety Bond and Liability Insurance.

No deficiencies observed during today's visit.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC809 (FAS) - (06/04)

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