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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803960
Report Date: 02/18/2022
Date Signed: 02/18/2022 12:52:05 PM

Document Has Been Signed on 02/18/2022 12:52 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:ELSA'S HOMEFACILITY NUMBER:
496803960
ADMINISTRATOR:HUMPHREY, NICHOLASFACILITY TYPE:
740
ADDRESS:10 CREEKVIEW COURTTELEPHONE:
(707) 539-5625
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 6DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Staff, Maria MejiaTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 11:00 AM, and met with staff, Maria Mejia. The inspection is focused on the Infection Control procedures and practices of this facility. LPA called administrator Alfonso Galvez who agreed to have LPA perform inspection with staff.

Upon entry LPA was screened for COVID symptoms and asked to sign in by staff. At primary entrance LPA observed visitor sign-in sheet. LPA conducted walk through of the facility with staff and observed COVID postings throughout. Mitigation plan was submitted by licensee and reviewed by Community Care Licensing.

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per staff, updated infection control guidelines and PINs are communicated to responsible parties verbally. Staff have completed Personal Protective Equipment (PPE) and infection control training through local public health. Staff have not been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census residents could isolate in their own rooms if they became ill. LPA observed necessary PPE to support a resident in isolation. Residents are monitored daily for symptoms and screened upon returning from outings.

Residents' emergency contact information has been updated and staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible to residents. Medications are centrally stored and inaccessible to residents. Facility is conducting COVID-19 surveillance testing per CCL guidelines. All residents have received their booster shot. All staff have received their booster shot, except for two who test weekly.

Continued on LIC 809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ELSA'S HOME
FACILITY NUMBER: 496803960
VISIT DATE: 02/18/2022
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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing.

There is an outdoor visitation area that is set up. LPA provided guidance to review PIN 22-07 regarding visitation.

LPA requested the following documents during the visit:

LIC 500
LIC 308
Liability Insurance
Emergency Disaster Plan
Administrator Certificate

No deficiencies cited during this inspection.

Exit interview conducted with Maria Mejia and a copy of this report was printed for the facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC809 (FAS) - (06/04)
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