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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803832
Report Date: 11/16/2021
Date Signed: 11/22/2021 02:34:44 PM

Document Has Been Signed on 11/22/2021 02:34 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CALIFORNIA MENTOR-CALISTOGA HOMEFACILITY NUMBER:
496803832
ADMINISTRATOR:CLEARY, CHARLENEFACILITY TYPE:
735
ADDRESS:5302 BADGER RDTELEPHONE:
(707) 538-9684
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 4CENSUS: 4DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Administrator, Charlene ClearyTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 1:50 PM, and met with administrator, Charlene Cleary. The inspection was focused on the Infection Control procedures and practices of this facility. LPA was initially greeted by staff, administrator arrived shortly. There are currently 4 clients in care.

Upon entry LPA was required to fill out a screening sheet and sign in. At primary entrance LPA observed both staff and visitor screening sheets. Administrator indicated clients are screened daily as well. COVID postings and postings indicating hand washing requirement upon entering were observed at the front door. Mitigation plan has been submitted and reviewed by Community Care Licensing (CCL).

LPA conducted walk through of the facility with administrator. 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 which was conducted by registered nurse at the facility. Staff have not been N95 fit tested but there is a plan in place to fit test staff. High touch surface areas are disinfected daily. Two bedrooms are private and one is shared. If a client were to become COVID+, clients would be moved to isolate the positive client. LPA confirmed facility has necessary PPE and supplies to support a resident in isolation. Clients' emergency contact information has been updated and staff confirmed they are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in garage cabinet as well as under the kitchen sink. Medications are centrally stored and locked in a medication cart which was observed in the living room. The facility has hygiene supplies and PPE located in the garage. Facility has a 100% vaccination rate for both staff and clients.

LPA was unable to print or obtain signatures during the inspection as a result of a computer malfunction. Inspection completed on 11/16/2021. Signatures obtained and exit interview conducted electronically.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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