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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801575
Report Date: 10/14/2022
Date Signed: 10/14/2022 04:02:55 PM


Document Has Been Signed on 10/14/2022 04:02 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:IDAHO CARE HOMEFACILITY NUMBER:
496801575
ADMINISTRATOR:RAMOS, CAROLINEFACILITY TYPE:
740
ADDRESS:3439 IDAHO DRIVETELEPHONE:
(707) 577-8233
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 5DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Administrator/Licensee, Caroline RamosTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection on 10/14/2022. LPA met with administrator/licensee, Caroline Ramos. The inspection is focused on the infection control procedures and practices of this facility.

Upon entry LPA was screened for COVID symptoms and asked to sign in. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of facility with administrator and observed COVID postings throughout. Infection control plan has been submitted to Community Care Licensing (CCL). Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Infection control guidelines and PINs are communicated to residents' families by administrator. Staff have completed Personal Protective Equipment (PPE) and infection control training. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPA confirmed licensee has necessary PPE and supplies to support a resident in isolation. Residents' emergency contact information has been updated. Toxins are secured and inaccessible. Medications are centrally stored in a locked cabinet located in the kitchen making them inaccessible to residents. Exit alarms on exit doors were working properly. Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. All staff and residents have been vaccinated/boosted. Third booster shot clinic is scheduled for 10/17/2022. LPA requested the following documents be submitted to CCL within 30 days of today's inspections:
LIC 308 Designation of Facility Responsibility
Liability Insurance
LIC 500 Personnel Report
Emergency Disaster Plan
LIC 9020 Client Roster
Exit interview conducted with administrator. No deficiencies observed during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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