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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803001
Report Date: 12/14/2021
Date Signed: 12/14/2021 10:31:32 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:SARAH'S RETIREMENT HOME FOR DD SENIORSFACILITY NUMBER:
496803001
ADMINISTRATOR:ARAYA, SARAHFACILITY TYPE:
740
ADDRESS:791 MCCONNELL AVENUETELEPHONE:
(707) 528-6623
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:6CENSUS: 3DATE:
12/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Sarah ArayaTIME COMPLETED:
10:41 AM
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Licensing Program Analysts (LPA) Victoria Willis and Caitlynn Felias arrived unannounced, to conduct an Annual Required inspection and met with Administrator, Sarah Araya. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPAs checked their own temperatures. Facility has a binder for visitors to sign in and complete a questionnaire with standard Covid screening questions. LPAs conducted a walk-through of the facility and observed Covid-19 posters including hand washing signs in the bathrooms. Per staff, clients are verbally reminded to wash and/or sanitize their hands. Hand sanitizer was observed throughout common areas of the facility and in resident rooms. Facility was a comfortable temperature and exits were free from obstructions. Facility is disinfected three times per day which includes disinfecting frequently touched surfaces. Clients are encouraged to wear masks when in the community. Staff were wearing masks during this inspection.

LPAs and Administrator discussed client activities and visitation. Facility has a designated outside area for visitation. LPAs confirmed with Administrator that they are conducting vaccine verification for visitors per Provider Information Notice (PIN) 21-40-ASC. Staff have been trained on proper use of Personal Protective Equipment (PPE). Staff have been N-95 fit tested. Facility has at least 30 days of PPE including gowns, surgical masks, N-95 masks, gloves, face shields and hand sanitizer that is accessible to staff. Facility also has at least a 30 day supply of medication.

Facility has submitted their Mitigation Plan and it was reviewed by CCL. Licensee regularly reviews and follows the guidance outlined by the Provider Information Notices (PINs) sent by the department. Facility is complying with current vaccination guidelines.

Staff and LPAs discussed their Emergency Disaster Plan. Hardwired smoke alarms and carbon monoxide detector were tested and operational.



No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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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