572700713-8-26-2020-21-AS-KWAS-BSV3QK-20200826182716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 572700713
Report Date: 08/25/2020
Date Signed: 08/26/2020 06:27:34 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 COTTONWOOD, LLC		FACILITY NUMBER:	572700713
ADMINISTRATOR:	CHENG, JULIANA		FACILITY TYPE:	740
ADDRESS:	1106 COTTONWOOD COURT		TELEPHONE:	(707) 592-4004
CITY:	DAVIS	STATE: CA	ZIP CODE:	95618
CAPACITY:	6	CENSUS:	DATE:	08/25/2020
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	01:24 PM
MET WITH:	Lourdes Pantig		TIME COMPLETED:	05:40 PM

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) Walters conducted a tele-visit inspection, on 8/25/2020 at approximately 1:40 PM to conduct a post licensing visit. LPA is conducting a tele-visit with House Manager, Lourdes Pantig (LP). Administrator, Julia Cheng was not available. The inspection is being conducted by tele-inspection due to COVID-19 precautions. The reader is advised that the LPA did not physically make a site visit. At the time of inspection there were 2 staff providing care and supervision for 6 residents. At 1:45 PM LP 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 1:57 PM LPA and House Manager observed that Exit 1 didn't have required auditory alarm. House Manager LP stated that they will place an auditory alarm on Exit 1 tomorrow. LPA and LP continued tour of resident's bedrooms. At 2:16 PM LPA observed medication in an unlocked drawer in R1's private bathroom. Both the door to the bedroom and bathroom were unlocked. LP was present. Staff immediately removed medication. Facility has all required postings including but not limited to the, Resident Bill of Rights and Ombudsman. Additional posters regarding proper hand washing, droplet precautions and sanitation pertaining to Covid-19. Facility 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 locked in cabinets in the laundry room. Water temperature tested at 105,107,105,105 degrees F. The thermometer on display read at 79 degrees. Continued on LIC 809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020

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 COTTONWOOD, LLC	FACILITY NUMBER: 572700713
	VISIT DATE: 08/25/2020

NARRATIVE

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Fire extinguisher was last serviced 10/1/2019. Staff tested carbon monoxide and they were found to be 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. Licensee agreed to submit staff's proof of annual training to LPA. Following the Change of Ownership, Licensee completed new Admission Agreements for all residents. A Centrally Stored Medication Log is maintained. LPA discussed facility's Disaster Preparedness with House Manager, including observing their Emergency supplies and where to find CCL's latest PIN. Licensee agreed to send the First Aid/CPR Certificate for each staff. An exit interview was conducted at 5:05 PM. 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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020

LIC809 (FAS) - (06/04)

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