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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801881
Report Date: 08/04/2021
Date Signed: 08/04/2021 11:30:58 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:SAINT MARY HOMECAREFACILITY NUMBER:
496801881
ADMINISTRATOR:HABTU, ASTERFACILITY TYPE:
740
ADDRESS:5039 PARKHURST DRIVETELEPHONE:
(707) 539-6677
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:4CENSUS: 1DATE:
08/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Licensee/Admistrator, Aster HabtuTIME COMPLETED:
11:45 AM
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Licensing Program Analysts (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 10:45 AM, and met with licensee/administrator Aster Habtu. The inspection is focused on the Infection Control procedures and practices of this facility. Facility currently has one resident.

At primary entrance LPA observed visitor sign-in sheet, hand sanitizer and thermometer for screening visitors. LPA conducted walk through of the facility with licensee/administrator and observed COVID postings throughout. Mitigation plan has been received and approved by community care licensing (CCL).

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per administrator, updated infection control guidelines and PINs are communicated to responsible parties verbally. Staff have completed Personal Protective Equipment (PPE) and infection control training through Kaiser. Staff have been N95 fit tested. 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 facility has necessary PPE equipment 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 locked garage cabinets. A 30 day supply of medications are stored in locked medication cabinet, making them inaccessible to residents. The facility has a sufficient supply of Personal Protective Equipment (PPE). Facility is conducting COVID-19 surveillance testing per CCL guidelines.

LPA and administrator discussed emergency disaster plan and confirmed there is a plan in place in case of evacuation.

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: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
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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