496803938-12-9-2021-21-AS-EGCS-C9K2KE-20211209162750

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803938
Report Date: 12/09/2021
Date Signed: 12/09/2021 04:28:22 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:	GARDENVIEW OF MARIAN HOME		FACILITY NUMBER:	496803938
ADMINISTRATOR:	SUMABAT, SHEILA		FACILITY TYPE:	740
ADDRESS:	2319 BISMARK COURT		TELEPHONE:	(707) 521-9597
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	6	CENSUS: 6	DATE:	12/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Staff Florentino Arcilla, and Raymundo Abrajano		TIME COMPLETED:	04:40 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 at approximately 3:20 PM, and met with staff, Florentino Arcilla and Raymundo Abrajano. Administrator was unavailable but LPA received verbal confirmation over the phone to perform inspection with staff. The inspection was focused on the Infection Control procedures and practices of this facility. Upon entry staff took LPA temperature and instructed LPA to sign in and answer screening questions. Hand sanitizer use was requested upon entry, shoes were also sanitized. At primary entrance LPA observed temperature logs and visitor sign-in sheet. Staff are also required to sign in. Staff showed LPA binder where resident screening forms are kept. LPA observed binder of COVID guidelines and Community Care Licensing (CCL) PINS available for visitors. LPA conducted walk through of the facility with staff and observed COVID postings throughout. Mitigation plan has been submitted and approved by CCL. 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. Infection control training was provided by Kaiser. Staff have been N95 fit tested. Licensee/administrator is an RN and is able to perform fit testing for staff. High touch surface areas are disinfected daily. One bedroom is shared but a plan is in place to isolate residents if necessary. LPA confirmed licensee has necessary PPE and supplies to support a resident in isolation. Residents' emergency contact information has been updated and staff confirmed they are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in garage. Medications are stored in a locked cabinet making them inaccessible to residents. Licensee/administrator confirmed that all residents and staff have received their booster shot and flu shot. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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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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: GARDENVIEW OF MARIAN HOME	FACILITY NUMBER: 496803938
	VISIT DATE: 12/09/2021

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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. LPA and staff discussed resident activities which include games and exercises. There is a visiting musician on Fridays. Visits are occurring both inside the facility as well as on the outdoor patio area.

Exit interview conducted with staff. LPA unable to print, will email report and supporting documentation to licensee.

No deficiencies cited during this inspection

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC809 (FAS) - (06/04)

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