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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801929
Report Date: 10/21/2021
Date Signed: 10/21/2021 03:46:58 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:FRIENDS HOUSEFACILITY NUMBER:
496801929
ADMINISTRATOR:CARENBAUER, JACLYNFACILITY TYPE:
741
ADDRESS:684 BENICIA DRIVETELEPHONE:
(707) 538-0152
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:145CENSUS: 76DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator, Jaclyn CarenbauerTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct an Annual inspection at approximately 2:40 PM, and met with administrator Jaclyn Carenbauer. This 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 by staff. At primary entrance LPA observed temperature logs, visitor sign-in sheet, and COVID postings. LPA conducted walk through of the facility with administrator and observed it to be clean and in good repair. Mitigation plan has been submitted and reviewed by Community Care Licensing (CCL).

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Updated infection control guidelines and PINs are posted on a bulletin board and accessible to residents. Staff have completed Personal Protective Equipment (PPE) and infection control training internally. 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 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 to residents in locked hallway closet. Medications are locked and inaccessible to residents in medication room. The facility has a sufficient supply of hygiene supplies. Assisted living has a 100% vaccination rate. All but one staff are vaccinated who continues to test weekly. Residents have private bedrooms where visitation is allowed but there is also a designated room for visitation if necessary. Facility is allowing residents in assisted living to have meals in the dining area.

No deficiencies cited during today's inspection. Exit interview conducted and a copy of this report was given to the administrator, Jaclyn Carenbauer.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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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