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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570317743
Report Date: 05/24/2022
Date Signed: 05/24/2022 01:06:32 PM

Document Has Been Signed on 05/24/2022 01:06 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:DAVIS SUMMER HOUSEFACILITY NUMBER:
570317743
ADMINISTRATOR:MAIRA GURROLAFACILITY TYPE:
735
ADDRESS:2525 EAST 8TH STREETTELEPHONE:
(530) 757-1294
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 14CENSUS: DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Julie Hunter, Co-Administrator and Julie Kirby,
Administrator
TIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Required Inspection and met with Julie Hunter, Co- Administrator and Julie Kirby, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.

LPA observed a screening station at the entrance of facility which had hand sanitizer, a thermometer, and a sign-in sheet for visitors. Visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Staff and client's temperatures are taken 2 times a day and is documented. LPA conducted a walk-through of the facility with Co-Administrator and observed COVID-19 precaution postings.
Staff clean and disinfect the facility 3 times each day. High touched surface areas are disinfected after each use. The facility has a designated visitation area indoors and outdoors (when the weather allows), provides virtual visits and phone calls for family to stay in contact with clients.

LPA observed 10 clients in care. Facility staff have completed training on infection prevention, symptoms, transmission and PPE use. N-95 Respirator Fit testing is in process.
LPA observed a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and gowns. All staff wore a face mask during this visit. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 to the California Department of Social Services.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.



No deficiencies cited during this inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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