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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801649
Report Date: 10/07/2021
Date Signed: 10/07/2021 01:18:08 PM

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:SUMMERFIELD CARE HOMEFACILITY NUMBER:
496801649
ADMINISTRATOR:WAINAINA, VICTORIAFACILITY TYPE:
740
ADDRESS:2725 SUMMERFIELD RD.TELEPHONE:
(707) 537-6669
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:5CENSUS: 5DATE:
10/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Victoria WainanaTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 12:00 PM. LPA was greeted by staff. Licensee and administrator arrived shortly. LPA met with administrator, Victoria Wainana and Licensee, Georgeta Valcu The inspection is focused on the Infection Control procedures and practices of this facility. There are currently 5 residents in care.

Upon entry LPA was screened for COVID symptoms and asked to sign in by staff. Staff requested LPA wear face shield in addition to face mask. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with licensee and administrator. LPA found the facility to be clean, free of obstructions, and a comfortable temperature. Mitigation plan has been submitted and approved by Community Care Licensing (CCL).

Per licensee and administrator, updated infection control guidelines and PINs are communicated to residents and responsible parties when they visit. Staff have completed Personal Protective Equipment (PPE) and infection control training through Kaiser. Administrator has been N95 tested but staff have not. 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 and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in a locked kitchen cabinet. A 30 day supply of medications are stored in a locked kitchen cabinet, making them inaccessible to residents. The facility has a sufficient supply of Personal Protective Equipment (PPE) and hygiene supplies located in the garage. Exit alarms on exit doors were working properly.

Continued on LIC809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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: SUMMERFIELD CARE HOME
FACILITY NUMBER: 496801649
VISIT DATE: 10/07/2021
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5 out of 5 residents are vaccinated and 7 out of 7 staff are vaccinated.

LPA requested copy of liability insurance during visit.

Administrator requested facility email be changed during visit.

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: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC809 (FAS) - (06/04)
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