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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803828
Report Date: 06/24/2022
Date Signed: 06/24/2022 01:41:34 PM


Document Has Been Signed on 06/24/2022 01:41 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:RINCON VALLEY GUEST HOMEFACILITY NUMBER:
496803828
ADMINISTRATOR:POPAT, SABRINAFACILITY TYPE:
740
ADDRESS:996 ESTES DRTELEPHONE:
(707) 539-6247
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 4DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Staff, Marlene GuidoTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year Inspection. LPA met with staff, Marlene Guido. This inspection is focused on the infection control practices and procedures of this facility. Licensee/administrator was not available but was notified over the phone.

Screening materials and sign in sheets are available at the front entrance. Visitors and staff are required to wear masks. LPA conducted walk through of the facility with staff and observed COVID postings throughout. Facility was a comfortable temperature and exits were free from obstructions. Mitigation plan has been submitted and approved by Community Care Licensing (CCL). LPA and staff discussed infection control plan due later this month.

Hand sanitizer is kept throughout the facility. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. Residents' emergency contact information has been updated and staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked garage. A 30 day supply of medications are stored in a locked kitchen cabinet, making them inaccessible to residents. Exit alarms on exit doors were working properly.

LPA and staff discussed staff training, resident activities, and reporting requirements. LPA provided copies of regulations. LPA requested licensee/administrator submit the following documents to CCL: LIC 500, LIC 610E, LIC 9020, LIC 308, Liability Insurance, Admin Certificate, Infection Control Plan

No deficiencies cited during today's inspection. Exit interview conducted with staff, Marlene Guido.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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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