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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801205
Report Date: 02/10/2022
Date Signed: 02/10/2022 10:04:53 AM


Document Has Been Signed on 02/10/2022 10:04 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:HOEN'S CARE HOMEFACILITY NUMBER:
496801205
ADMINISTRATOR:ALCONES, LILY O.FACILITY TYPE:
740
ADDRESS:1618 MARIPOSA DRIVETELEPHONE:
(707) 573-8922
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 6DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Arthur Alcones and Lily AlconesTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 8:30 AM, and met with licensee/administrator Arthur and Lily Alcones. The inspection is focused on the Infection Control procedures and practices of this facility. LPA was initially greeted by staff, licensee/administrator arrived shortly.

Upon entry LPA was screened for COVID symptoms and asked to sign in by staff. At primary entrance LPA observed visitor sign-in sheet. LPA conducted walk through of the facility with licensee/administrator and observed COVID postings throughout. Mitigation plan was submitted by licensee and reviewed by Community Care Licensing.

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per administrator, updated infection control guidelines and PINs are communicated to responsible parties verbally. Staff have completed Personal Protective Equipment (PPE) and infection control training through local public health. Staff have been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census, four residents could isolate in their own rooms if they became ill. Two residents share a bedroom, but a spare room is available to isolate. LPA observed COVID kit with PPE to support a resident in isolation. Residents are screened twice a day for symptoms.

Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible to residents. Medications are centrally stored and inaccessible to residents. Facility is conducting COVID-19 surveillance testing per CCL guidelines. All residents have received their booster shot. All staff have received their booster shot.

Continued on LIC 809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2022
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: HOEN'S CARE HOME
FACILITY NUMBER: 496801205
VISIT DATE: 02/10/2022
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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. LPA and administrator discussed resident activities which include music therapy, light walks, and coloring. Facility has a new deck which residents are brought out to. Visitation is primarily on the backyard patio area as well as on the front porch. Visitation is allowed indoors though.

LPA requested the following documents during the visit:

LIC 500
LIC 308
Liability Insurance
Emergency Disaster Plan
Administrator Certificate

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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