496803544-8-27-2021-21-AS-CFGS-C6AMHH-20210827093734

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803544
Report Date: 08/25/2021
Date Signed: 08/27/2021 09:37:40 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:	LITTLE BIRD ASSISTED LIVING		FACILITY NUMBER:	496803544
ADMINISTRATOR:	FRANCO, KATIE		FACILITY TYPE:	740
ADDRESS:	511 WEBSTER STREET		TELEPHONE:	(707) 559-5793
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94952
CAPACITY:	6	CENSUS: 6	DATE:	08/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Chris Conradt - Ass. Administrator		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by assistant administrator Chris Conradt. Facility has 6 residents with 1 resident under hospice care. Facility has activities for residents such as singer outside, movie night, group working exercises, walks, and other activity plans for residents during the day. LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 8/25/2021 with staff Chris, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 07/2021 at the time of the visit. Smoke Detectors & Carbon monoxide detector was found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet under the kitchen sink. Dangerous items were stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for clients. Residents' bedrooms have lighting & appropriate furnishings, and mattress pads are available for clients at the facility. Facility understands that hot water temperatures must measure degrees F within Title 22 acceptable regulations of 105 to 120 degrees F. Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in outside garage. Facility has hired or admitted anyone new since COVID-19. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: LITTLE BIRD ASSISTED LIVING	FACILITY NUMBER: 496803544
	VISIT DATE: 08/25/2021

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Residents’ medications are stored and locked in the kitchen cabinet. Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility, however; licensee/admin stated that they are able to wear masks when going on outings. All staff had masks on during this visit.

In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Residents have also available Zoom and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing.

LPAs advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted quarterly with the last one being conducted on 8/16/2021.

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC809 (FAS) - (06/04)

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