496803544-8-15-2022-21-AS-CFGS-CHBTST-20220815145923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803544
Report Date: 08/15/2022
Date Signed: 08/15/2022 02:59:29 PM

Document Has Been Signed on 08/15/2022 02:59 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:	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:	08/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Chris Conradt - Ass. Administrator		TIME COMPLETED:	12:50 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 staff Cecilia Pacheco who contacted assist. Administrator. Chris Conradt arrived during this visit and met with LPA. There are 6 residents with 3 under hospice at facility. Facility has activities planned for residents during the day. LPA arrived at the facility and had her temperature checked and logged. During facility tour on 8/15/2022 with licensee/administrator; 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 06/2022 at the time of the visit. Sample test of Carbon monoxide detector was found to be operational during this 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. Facility has no residents' with a special diet at this time. Toxins are stored in a locked laundry and garage area. Dangerous items were stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings. Disaster drills are being conducted with records for last fire drill on 8/1/2022. Continued 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: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LITTLE BIRD ASSISTED LIVING	FACILITY NUMBER: 496803544
	VISIT DATE: 08/15/2022

NARRATIVE

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Infection Control:
Facility has submitted a mitigation program plan that has been approved, and infection control plan has been submitted. Some posters have been placed at entrance and throughout of the facility. Facility has hand sanitizer available; visitors and staff before coming into work have temperature checked. Facility has PPE supply stored in garage area. There has been new staff hired and new resident’s admission since COVID. Residents’ medications are stored and locked in the kitchen cabinet. Facility has a 30-day supply of medication for clients. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Visitors are being allowed. Residents have also available virtual and telephone calls when contacting with family members and others. Staff stated that all required COVID training is on file in addition to N-95 fit testing for staff.

There were no deficiencies cited at this time.

Department is requesting facility to submit the following update documents by 8/22/2022:

LIC 308 Designated
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Certificate of Liability Insurance
Copy of Administrator Certificate

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

LIC809 (FAS) - (06/04)

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