496803915-7-16-2020-21-AS-DALO-BRKVTS-20200716164338

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803915
Report Date: 07/16/2020
Date Signed: 07/16/2020 04:44:48 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:	MARIE'S CARE HOME		FACILITY NUMBER:	496803915
ADMINISTRATOR:	BISCOCHO, LIZA		FACILITY TYPE:	740
ADDRESS:	7334 CARIOCA CT.		TELEPHONE:	(707) 794-0591
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	6	CENSUS: 4	DATE:	07/16/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Liza Biscocho-Licensee/Administrator		TIME COMPLETED:	02:10 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) Alviso, conducted a prelicensing tele-inspection, on 7/16/2020 at approximately 11:00AM, and spoke with applicant Liza Biscocho, who will also be the facility's designated Administrator. This is a change of ownership application, and Applicant is currently the Administrator for the current license, Susie's Care Home. Once this application is approved, Mrs. M. Biscocho will be the Licensee and Administrator. This tele-inspection is being conducted for a pre-licensing and a component III orientation. The inspection is being conducted by tele-inspection due to COVID-19 precautions. LPA conducted the inspection by video conference call; The reader is advised that the LPA did not physically make a site visit. Rohnert Park Fire Inspector approved a fire clearance for 6 nonambulatory residents, which includes 1 bedridden approval- effective 7/2/2020. Facility has applied for a hospice waiver for three (3); Hospice waiver will be approved and effective once application is licensed. Facility submitted a dementia plan to be approved to care for dementia residents; Dementia plan is part of the facility's plan of operation, and will be effective upon licensure. LPA observed comfortable furnishings throughout the facility. The facility has a small deck in the front of the house with a small table with chairs. The backyard cement patio outside is large, with patio furnishings for resident use. There was sufficient lighting throughout the facility in resident rooms, common areas, bathrooms, and hallways. The grounds were free of any apparent hazards, and exits were clear. No bodies of water. No firearms. LPA observed a medication cabinet locked, making all medications inaccessible to residents in care. Kitchen had sufficient food supply for residents in care. Continued on LIC809C...

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2020

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: MARIE'S CARE HOME	FACILITY NUMBER: 496803915
	VISIT DATE: 07/16/2020

NARRATIVE

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There was a sufficient supply of paper products, hygiene products, cleaners, and other items for resident use. All bathrooms had grab bars, and non-slip flooring/mats for resident use. All exit doors had auditory alarms working properly. Smoke alarms, carbon monoxide detectors were working properly during the inspection. Fire extinguishers were tagged and inspected as required. Facility had emergency supplies to meet requirement for the 72 hour shelter in place. Postings noted to be current and in compliance with regulations. Hot water was checked,105F, and is within regulation of no lower than 105F and no higher than 120F. LPA advised that the hot water could be turned up a little but ensure hot water temperature does not go above 120F. Applicant stated their understanding. Facility does have an emergency disaster plan on-site, and facility does have a generator that can be used as needed for charging things like cell phones, batteries, lights/lanterns. Toxins/cleaners will be locked and secured and inaccessible to residents in care. Facility has a supply of Personal Protective Equipment (PPE) for use as needed. Station set up at front door area with sanitizer gel, and where a staff person on duty will ensure staff, and essential visitors are screened, temperature taken, and questions asked of each essential visitor/staff as part of Covid 19 precautions in place. All postings required were posted, and visible upon arriving to the front entrance door outside of the facility.

LPA conducted a component III orientation with Applicant Liza Biscocho.

Pre-Licensing is complete and this facility has no apparent health hazards and/or concerns observed during this tele-inspection.

**Applicant is advised any structural changes to facility may require further inspection before final approval.

Copy of report to be faxed to Applicant for signature. LPA will forward a copy to the application unit in Sacramento; The application analyst will notify the applicant the status of the application.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2020

LIC809 (FAS) - (06/04)

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