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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801248
Report Date: 02/23/2022
Date Signed: 02/23/2022 03:34:05 PM


Document Has Been Signed on 02/23/2022 03:34 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SARAH'S ELDERLY CAREFACILITY NUMBER:
496801248
ADMINISTRATOR:LAWRENCE, JACQUELINEFACILITY TYPE:
740
ADDRESS:130 ANNA DR.TELEPHONE:
(707) 838-7237
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:6CENSUS: 4DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Alyssa McDonald, AdministratorTIME COMPLETED:
03:43 PM
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At approximately 1:50PM, Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced to conduct an Annual required Inspection and met with Administrator, Alyssa McDonald. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPAs checked their temperatures and completed a questionnaire with standard Covid screening questions. LPAs conducted a walk-through of the facility and observed the following: Facility had COVID-19 posters throughout the facility including at the entry way. Facility had hand-washing signs located at the kitchen sink but not in the bathroom. LPAs discussed with Administrator to add hand-washing signs. Based on review of visitor log, staff are screened at the beginning of each shift. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was available in common areas. LPAs observed staff wearing masks during this visit. Commonly touched surfaces are disinfected three times per day during each shift.

LPAs and Administrator discussed resident activities and visitation.

Upon Employee Roster review, LPAs discovered a staff who was currently going through the Fingerprint Exemption Process. Per conversation with Administrator, facility was provided a letter from CCL that allows the employee to work in facility while they are going through the exemption process. Staff initiated the process while working at another home licensed by the Licensee and the letter is in the other home. Administrator agreed to send letter to LPAs no later than Friday, February 25, 2022.

Facility has at least a 30 day supply of Personal Protective Equipment (PPE) including surgical masks, gloves, gowns, and hand sanitizer.
Fire Extinguisher was last serviced November 2021. Smoke Detector and carbon monoxide detector were tested and operational.

No Deficiencies cited during this inspection.


SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
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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