496804055-7-12-2022-21-AS-SHAN-CG9P4S-20220712105936

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804055
Report Date: 07/12/2022
Date Signed: 07/12/2022 11:00:20 AM

Document Has Been Signed on 07/12/2022 11:00 AM - 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:	ALTA CARE HOME		FACILITY NUMBER:	496804055
ADMINISTRATOR:	MONTE, AIRA MELANIE V.		FACILITY TYPE:	740
ADDRESS:	96 ALTA DRIVE		TELEPHONE:	7075087634
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 3	DATE:	07/12/2022
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Licensee' Laarni & David Lockerbie		TIME COMPLETED:	11:00 AM

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) Hansen conducted an unannounced post-licensing infection control inspection to this facility and was welcome by Licensee Laarni & David Lockerbie. Facility has 3 residents with 1 dementia diagnosis. At entrance there is a credenza with binder for visitors to input temperatures and hand sanitizer were LPA had temperature taken by Licensee and logged. During tour of the facility on 7/12/2022 with licensee Laarni, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample tour of resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 1/26/2022. Hot water temperature measured between 110.6 degrees F and 112.1degrees F in 2 out of 2 resident’s bathroom faucets which are within Title 22 acceptable regulation of 105 to 120 degrees F. Toxins are stored in a locked hallway closet & locked cabinet under sink. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available. Sample resident’s bedrooms have lighting & appropriate furnishings. Infection Control: Facility has submitted a mitigation program plan that was approved and have submitted Infection Control Plan. Posters have been placed at facility. Facility has PPE supply stored in the front hallway credenza and garage. Residents’ medications are centrally stored and locked in cabinets above the office desk. Facility has a 30-day supply of medication for residents. Residents do not wear masks inside the facility. Facility offers activities of walks and puzzles. In addition, facility has a designated area for visitors in the backyard, living room, and/or in the bedrooms when possible. Residents have also available Zoom and telephone calls when contacting with family members and others. Staff had PPE training required on file and have been N-95 fit tested except one new staff who just started 7/12/2022 which will be completed this month. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

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: ALTA CARE HOME	FACILITY NUMBER: 496804055
	VISIT DATE: 07/12/2022

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LPA reviewed Licensing Information System (LIS) with licensee who stated that is correct and updated at this time. In addition, LPA advised facility to contact County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1^st Aid certification for staff which files were reviewed.
Administrator Certificate’s for Aira Melanie Monte # 6056005740 Exp. 8/29/2022
All staff have received COVID booster vaccinations and exclusively work at this facility.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 7/27/2022 to SRRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 9020 Register of Facility Resident’s

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC809 (FAS) - (06/04)

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