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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 572700712
Report Date: 02/07/2023
Date Signed: 02/07/2023 02:01:36 PM


Document Has Been Signed on 02/07/2023 02:01 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:CAREWELL AT SPANISH BAY LLCFACILITY NUMBER:
572700712
ADMINISTRATOR:PANTIG, LOURDESFACILITY TYPE:
740
ADDRESS:39374 SPANISH BAY PLTELEPHONE:
(530) 757-2027
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:6CENSUS: 6DATE:
02/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Paulin Pantig, AdministratorTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced 1 year required inspection and met with Administrator Paulin Pantig. The inspection is focused on the Infection Control procedures and practices of this facility.

All visitors, essential visitors, and staff are screened upon entry; temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened and observed daily for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature of 70 degrees with all exits free from obstruction. Facility has activities going on throughout the day: games, puzzles, piano, and singing. Toxins are stored in locked cabinets. Sharps are locked in cabinet in kitchen. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored in a locked cupboard in kitchen; inaccessible to residents. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment (PPE). Administrator, staff and one visitor had a mask on during the LPA's inspection. Facility is licensed for 6 non-ambulatory residents; there are currently 6 residents in care. There is an approved hospice waiver for six (6) residents. Mitigation plan was approved by the Department on 04/22/21 and the Licensee has submitted an Infection Control Plan.

No deficiencies during today's inspection.
No citations issued.
Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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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