<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803849
Report Date: 05/26/2022
Date Signed: 05/26/2022 03:56:45 PM


Document Has Been Signed on 05/26/2022 03:56 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:ADOM MANOR CARE HOMEFACILITY NUMBER:
496803849
ADMINISTRATOR:KARIKARI, EVAFACILITY TYPE:
740
ADDRESS:2543 TACHEVAH DRTELEPHONE:
(707) 526-6895
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 5DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Administrator, Eva KarikariTIME COMPLETED:
04:10 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) Erik Gonzalez Campos arrived unannounced to conduct a Required-1 Year Inspection and met with licensee/administrator Eva Karikari. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPA was screened for COVID symptoms and asked to sign in by licensee. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with licensee and observed COVID postings throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL).

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per licensee, updated infection control guidelines and PINs are communicated to residents and responsible parties through an on-site information resource binder. Staff have completed Personal Protective Equipment (PPE) and infection control training through Kaiser. Staff were N95 fit tested last year, will be tested again this year through Concentra. 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 licensee confirmed staff are familiar with 911 procedures and protocols. A 30 day supply of medications are stored in a locked cabinet, making them inaccessible to residents. The facility has a sufficient supply of Personal Protective Equipment (PPE) and hygiene supplies located the garage. All residents are vaccinated and boosted. Surveillance testing is only required for staff if not vaccinated and an exception is documented,

LPA requested the following documents during the visit: LIC 308, LIC 9020, Emergency Disaster Plan, Liability Insurance, LIC 500. No deficiencies observed during the inspection. Exit interview conducted with administrator and a copy of the report left for the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1