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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 572700712
Report Date: 08/26/2020
Date Signed: 08/26/2020 06:39:39 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:CAREWELL AT SPANISH BAY LLCFACILITY NUMBER:
572700712
ADMINISTRATOR:CHENG, JULIANAFACILITY TYPE:
740
ADDRESS:39374 SPANISH BAY PLTELEPHONE:
(530) 231-2301
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:6CENSUS: 5DATE:
08/26/2020
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Lourdes PantigTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Walters conducted a tele-visit inspection, on 8/26/2020 at approximately 12:06 PM to conduct a post licensing visit. LPA is conducting a tele-visit with House Manager, Lourdes Pantig. Licensee, Robert Coleman was not available. The inspection is being conducted by tele-inspection due to COVID-19. The reader is advised that the LPA did not physically make a site visit. At the time of inspection there were 3 staff providing care and supervision for 5 residents.

At approximately 12:08 PM Licensee conducted a walk through via video conferencing and LPA observed that resident rooms were furnished per regulations and bathrooms were equipped with nonskid mats and handrails for safety. At 12:10 PM LPA and LP observed a living room area that had been converted into a bedroom. The bedroom contained a hospital bed and a closet with clothes items. LP stated that this room would be used as a bedroom after the facility receives a permit. LPA's continued tour of resident rooms and bathrooms.

See 809 C.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2020
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: CAREWELL AT SPANISH BAY LLC
FACILITY NUMBER: 572700712
VISIT DATE: 08/26/2020
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Facility has required postings including but not limited to the CCL Complaint Poster, Resident Bill of Rights and Resident Rights to Resident Councils and Ombudsman poster located in the hallway. Additional posters regarding proper hand washing, droplet precautions and sanitation pertaining to Covid-19 were located at the entrance of the facility. Facility also has a sanitation station set up at the entrance to the facility in order to comply with Covid-19 precautions. Facility has at least two days of perishable and one week of nonperishable foods. Facility has space indoors and outdoors for resident activities. Disinfectants and Toxins are located in locked laundry room. Water temperature tested between 105 and 120 degrees F, which is within the allowable limits required by regulation. LPA consulted with Licensee, where PIN’s and resources regarding COVID-19 are located on CDSS website.

Fire extinguisher was last serviced 10/4/2019 Staff tested carbon monoxide monitor and it was operational.

Resident and staff records are maintained. LPA was unable to conduct a thorough review of records but did confirm that each staff has an active First Aid/CPR Certificate. LP agreed to submit staff's proof of annual training, a copy of an Admission Agreement as well as LIC 500 to LPA. Following the Change of Ownership, Licensee completed new Admission Agreements for all residents. Medication is centrally stored and locked in a cabinet. A Centrally Stored Medication Log is maintained. LPA discussed facility's Disaster Preparedness with including observing their Emergency supplies. LP agreed to send the First Aid/CPR Certificate for each of staff.

An Exit Interview was conducted at 2:55 PM with Administrator, Robert Coleman and House Manager, Lourdis Pantig. A technical advisory issued. LPA provided a copy of regulation. A copy of this report was also given to Administrator.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2020
LIC809 (FAS) - (06/04)
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