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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801600
Report Date: 06/17/2021
Date Signed: 06/17/2021 11:46:44 AM

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:MT. VERNON GARDENSFACILITY NUMBER:
496801600
ADMINISTRATOR:DELLER, EMILCE & KIMFACILITY TYPE:
740
ADDRESS:3754 MT. VERNON RD.TELEPHONE:
(707) 829-3796
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:6CENSUS: 6DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Emilce Deller (Licensee)TIME COMPLETED:
12:05 PM
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Licensing Program Analysts (LPAs) Cuadra and Lopez conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Licensee, Emilce Deller. LPA conducted a Risk Assessment call with Licensee prior to the visit. There were 6 residents in care present at the facility.

Upon arrival, LPA observed that facility has a table just inside the entrance to the facility with hand sanitizer, a thermometer and a sign in sheet. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters throughout the facility that included hand-washing signs in each bathroom. Per conversation with Licensee, they check the temperature of visitors and asks them screening questions. LPA asked if 25% of staff are surveillance testing weekly and she stated they still doing it. LPA confirmed that facility is checking resident and staff temperatures daily but the information is not being documented. LPA observed four residents in care watching television in the living room. Facility has a 30-day supply of medication for residents. Residents do not typically wear masks inside the facility but have them available. Facility staff have completed PPE training but have not yet been N-95 Fit tested. Facility has submitted a Covid19 Mitigation Plan which is currently under review. LPAs/staff observed PPE supplies including, masks, gloves, hand sanitizer. All staff had masks on during this visit.

LPA provided the following guidance to Licensee:
· Document all temperature reading and screening questions for staff and residents to help track possible onset of symptoms.
· Complete N-95 Fit Testing for all staff

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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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