496803929-9-21-2020-21-AS-MCUA-BTNSRN-20200921140638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803929
Report Date: 09/21/2020
Date Signed: 09/21/2020 02:07:08 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:	MAGGIE'S CARE HOME		FACILITY NUMBER:	496803929
ADMINISTRATOR:	GARCIA, MAGGIE		FACILITY TYPE:	740
ADDRESS:	916 RENEE COURT		TELEPHONE:	(707) 568-7497
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95401
CAPACITY:	6	CENSUS: 3	DATE:	09/21/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:28 PM
MET WITH:	Applicants Maggie and Heherson Garcia		TIME COMPLETED:	02:00 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) Cuadra conducted the Pre-licensing Inspection via video conferencing due to Covid-19 precautions with Applicants, Maggie and Heherson Garcia. Applicant has applied for a Change of Ownership for this already existing facility. All facility bedrooms have all personal accommodations. Each bed has a mattress pad. All bedrooms have adequate lighting, closet and dresser space. There is a common bathroom with a tub/shower. Facility received an approved fire clearance September 17, 2020 that allows for six non-ambulatory residents. Applicant conducted a walk through via video conference and LPA observed that resident rooms were furnished per regulations and bathrooms were equipped with nonskid mats and grab bars for safety. LPA observed required postings (LTCO, CCL Complaint poster, visitor policy, employee rights and personal rights). in addition to COVID-19 required visitation postings. Facility has a sanitation station set up at the entrance to the facility in order to comply with Covid-19 precautions. Facility are screening staff or essential visitors for symptoms. The facility staff was observed wearing mask during the virtual tour of main entrance, doors, common areas, dining rooms and kitchen area. Facility provides assistance with family communication via telephone or video call. Facility has adequate dishes and cooking materials to provide meals to residents. Facility has at least two days of perishable and one week of nonperishable foods. Food supplies are maintained in the kitchen as well as a surplus of food in the garage. There is a deep freezer and upright refrigerator in the garage. Facility has space indoors and outdoors for resident activities. Cabinet containing cleaning supplies and kitchen drawer containing other items that could pose a risk were locked. Applicant tested water, reading at 107.6 and 107 Fahrenheit degrees which is within allowable range. Fire extinguisher was last inspected April 2020. Facility has hardwired combination smoke/ carbon monoxide detectors that were tested and operational. Exit doors have auditory alerts that were functional at time of visit. Resident and staff records are maintained. Continues on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2020

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: MAGGIE'S CARE HOME	FACILITY NUMBER: 496803929
	VISIT DATE: 09/21/2020

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Continued from LIC809...

LPA confirmed with Applicant that if current residents choose to stay after Change of Ownership, a new Admission Agreement will need to be completed. Applicant understood. Medication is centrally stored and locked in a closet. A Centrally Stored Medication Log is maintained. LPA discussed facility's Disaster Preparedness with Applicant including observing their Emergency supplies. Applicant showed LPA the contents of their First Aid Kit.

Component III Orientation was completed with Administrator. Pre-licensing passed and COMP III completed. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation.

LPA will provide this report to the Centralized Application Unit to continue application process.

No deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2020

LIC809 (FAS) - (06/04)

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