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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801426
Report Date: 06/14/2022
Date Signed: 06/14/2022 01:45:24 PM

Document Has Been Signed on 06/14/2022 01:45 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:THRUSHWING HOMEFACILITY NUMBER:
496801426
ADMINISTRATOR:KRYSTAL AMBRECHTFACILITY TYPE:
735
ADDRESS:128 THRUSHWING AVENUETELEPHONE:
(707) 843-4880
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 4CENSUS: 4DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Krystal AmbrechtTIME COMPLETED:
01:55 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 Willis arrived unannounced, to conduct an Annual Required inspection and met Administrator, Krystal Ambrecht. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by the Administrator for Covid-19 symptoms and temperature was taken. Facility has Covid-19 posters at the front door and a hand washing sign in the kitchen near the sink. LPA confirmed that staff are conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASCs. Facility is unable to keep posters in restrooms and in other parts of the facility as they get removed by clients. Facility is unable to store hand sanitizer in client rooms per safety precautions but clients and staff are encouraged to wash their hands frequently and hand sanitizer is centrally located. Per staff, infection control is regularly discussed with clients and staff. Facility was a comfortable temperature and exits were free from obstructions. Staff and clients are screened for Covid-19 symptoms once per day and results are documented. Commonly touched surfaces are disinfected at least once per shift and as needed.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is located in the living room and is accessible to staff who need it. Staff continue to wear masks while in the facility, per CCL guidance.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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 2
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: THRUSHWING HOME
FACILITY NUMBER: 496801426
VISIT DATE: 06/14/2022
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
26
27
28
29
30
31
32
Continued from LIC809

Facility has a designated visitation area outside and does allow for inside visitation per CCL guidance though most visitors choose to visit clients outside or off-site. Staff continue to be trained regarding PPE and infection control. Administrator is N95 fit tested and is working on having other staff fit tested. Clients are gradually returning to day program. Facility maintains a 30 day supply of medication.

Administrator tested smoke alarms during inspection. Administrator and LPA discussed their Emergency Disaster Plan and the Infection Control Plan. The Infection Control Plan is due to CCL no later than 6/30/2022.

LPA discussed the Administrator Certificate with Administrator, Krystal Ambrecht. Per Administrator, they sent their renewal paperwork in, in February. LPA asked Administrator to follow up with the Administrator Certification Unit and possibly resend their paperwork.

Licensee/Administrator to submit updates of the following documents by 7/14/2022:

LIC 500 Personnel Summary
LIC 402 Surety Bond
LIC 610 Emergency Disaster Plan (if any changes)
LIC 9020 Register of Facility Clients

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2