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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803289
Report Date: 02/09/2023
Date Signed: 02/09/2023 12:49:19 PM

Document Has Been Signed on 02/09/2023 12:49 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BEACHWOOD HOUSE, INC.FACILITY NUMBER:
496803289
ADMINISTRATOR:CABIE, BENJAMINFACILITY TYPE:
735
ADDRESS:1177 BEACHWOOD DRIVETELEPHONE:
(707) 332-9865
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 4CENSUS: 4DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:59 AM
MET WITH:Jhanell Edmalin (House Manager)TIME COMPLETED:
01:04 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with House Manager Jhanell Edmalin. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA/House Manager initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Commonly touched surfaces are disinfected at least twice per day. Facility does perform daily screening of staff and residents and documents it. Facility is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control, donning and doffing of Personal Protective Equipment PPE and have been N95 fit tested. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguisher was last serviced June 2022. Smoke Detectors and Carbon Monoxide detector were tested and found operational. All clients do attend to day program and facility provides activities for clients as well.

Facility will provide copies of the following documents by 2/23/23: Designation of Responsibility (LIC308), Administrative Organization (LIC309), Affidavit Regarding Client Cash Resources (LIC400), Surety Bond, Control of Property (Deed, property tax, etc), Personnel Report (LIC500) and LIC 610 Emergency Disaster Plan. Exit interview conducted with House Manager and a copy of this report was given.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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