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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804133
Report Date: 07/24/2023
Date Signed: 07/31/2023 04:09:22 PM


Document Has Been Signed on 07/31/2023 04:09 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/28/2023 10:32 AM

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

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"AMENDED" This is an amended version of the original report created on July 24, 2023-SEE BELOW.

Licensing Program Analyst (LPA), Farhaan Sarangi arrived announced at Rincon Valley Assisted Living LLC for the purpose of conducting a Pre Licensing Inspection. LPA was greeted at the front door by Caregiver, Rahel Gurja and was granted access into the facility. Fire Clearance approved for 6 non-ambulatory. Administrator presented the LPA with the Administrators Certificate for Residential Care for the Elderly (Standard Certificate #6064861740 with an expiration of January 7, 2025). First Aid Certificate expires on November 16, 2024.

LPA and Licensee/Administrator toured the one story facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on May 2023 at the time of the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Auditory Devices were operational during the Pre Licensing Inspection. Emergency Generator was observed on the side of the house and in a shed. First Aid kit was inspected and found to be appropriate during the inspection. Water temperature in 3 of 3 residents bathroom measured at 113 degrees and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Knives and other hazardous items were locked and inaccessible to residents in care. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Cleaning products and other toxins are located in the locked laundry room and inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents in care during the Pre Licensing Inspection. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. (Report continued on LIC 809C)
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
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: RINCON VALLEY ASSISTED LIVING LLC
FACILITY NUMBER: 496804133
VISIT DATE: 07/24/2023
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"AMENDED" This is an amended version of the original report created on July 24, 2023-SEE BELOW.

Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + or any other infectious diseases in the facility. LPA discussed the Infection Control Plan with the Licensee/Administrator in detail. LPA discussed the Emergency Disaster Plan. LPA was made aware that there was an update to the Emergency Disaster Plan that will be sent to the Application Analyst in the Department.

Component III was discussed in detail.

Exit interview was conducted, and a copy of this report was given to the Caregiver. LPA will forward this report to the assigned Application Analyst in our Department; The Application Analyst will notify the Applicant of the status of the application.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4