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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803796
Report Date: 11/23/2021
Date Signed: 11/23/2021 01:49:13 PM

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:WILLOW GLEN HOMEFACILITY NUMBER:
496803796
ADMINISTRATOR:HUNTER, GINAFACILITY TYPE:
740
ADDRESS:4750 COUNTRY CLUB DRTELEPHONE:
(707) 708-2199
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: 6DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee, Zoe TeeterTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 12:30 PM, and met with licensee Zoe Teeter. The inspection was focused on the Infection Control procedures and practices of this facility. LPA was initially greeted by staff, licensee arrived shortly. There are currently 6 residents in care.

At primary entrance LPA observed visitor screening sheets and a thermometer. COVID posting were observed posted at the front door. Mitigation plan has been submitted and reviewed by Community Care Licensing (CCL).

LPA conducted walk through of the facility with licensee. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Staff have completed Personal Protective Equipment (PPE) and infection control training through Kaiser. Some staff have been N95 fit tested. High touch surface areas are disinfected daily. There are two shared bedrooms but a plan is in place to move residents if someone were to become ill. LPA confirmed facility has necessary PPE and supplies to support a resident in isolation.

Residents' emergency contact information has been updated and staff confirmed they are familiar with 911 procedures and protocols. Toxins are secured and inaccessible to residents. Medications are centrally stored and inaccessible to residents. The facility has hygiene supplies and PPE located in the garage.

Facility conducts some infrequent surveillance testing. Facility has a 100% vaccination rate for both staff and residents. Half of the clients have received their booster shot, the other half to receive it on Monday.

Continued on LIC 809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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: WILLOW GLEN HOME
FACILITY NUMBER: 496803796
VISIT DATE: 11/23/2021
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Common areas allow for social distancing. A patio area is available outdoors for visitation but visitation is allowed indoors. Facility keeps copies of the vaccination cards for residents' families.

The following documents were requested during today's inspection:

Liability Insurance
Personnel Report
Administrator Certificate
Client Roster
Emergency Disaster Plan

Exit interview conducted with licensee and a copy of the report printed for the facility.

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC809 (FAS) - (06/04)
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