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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801932
Report Date: 10/29/2021
Date Signed: 10/29/2021 12:58:02 PM

Document Has Been Signed on 10/29/2021 12:58 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:DUNGARVIN CALIFORNIA LLCFACILITY NUMBER:
496801932
ADMINISTRATOR:HENRY, HAZELFACILITY TYPE:
775
ADDRESS:433-439 BEAVER STTELEPHONE:
(707) 543-5895
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 75CENSUS: 38DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator, Hazel HenryTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and met with Administrator, Hazel Henry. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed Covid-19 posters on or near exterior doors and a centralized screening area. LPA was asked to fill out and sign a document indicating they did not have Covid-19 symptoms and their temperature was taken by staff. LPA conducted a walk-through of the facility which included three separate suites with the Administrator and observed Covid-19 posters throughout that included hand washing signs in restrooms. Facility has a designated isolation room if a client exhibits symptoms while in program. At this time, the day program is split into a morning session and an afternoon session with each having a small group of clients to allow for social distancing. Meals are not currently being served at program unless it is medically necessary. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer stations were observed throughout the facility. Observed staff had masks on during this visit. There were not any clients at facility during this inspection.

Staff have completed PPE training. Commonly touched surfaces are disinfected three times per day and after each use. Facility asks for clients to screen at home prior to coming to program. Additionally, clients are screened prior to getting in the facility van if they are transported by van or once they arrive at program. The screening area for clients is outside to allow for proper social distancing.

Facility has submitted and the department has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is accessible to staff who need it.

Facility continues to test per CCL guidance.

No deficiencies cited during this inspection.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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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