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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 575001806
Report Date: 12/10/2021
Date Signed: 12/10/2021 01:29:08 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:ST. CLAIRE'S HOME FOR THE ELDERLYFACILITY NUMBER:
575001806
ADMINISTRATOR:DUGYON, JULIETFACILITY TYPE:
740
ADDRESS:2551 MEADOWLARK CIRCLETELEPHONE:
(916) 307-8068
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:6CENSUS: 2DATE:
12/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Juliet Dugyon, LIcensee/AdministratorTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted 1 year required inspection and met with Administrator/Licensee Juliet Dugyon. The inspection is focused on the Infection Control procedures and practices of this facility.

LPA toured the facility with Administrator on 12/10/2021 at approximately 12:00 PM. All visitors, essential visitors, and staff are screened upon entry; temperatures are taken, and screening questions are asked, and all information is logged. Residents are screened and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. There was adequate dry food for at least a week and fresh foods for at least 2 days. Medications were stored locked making them inaccessible to residents and staff that do not handle medications. Sharps are stored and locked; inaccessible to residents. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible as required. Facility has a sufficient supply of personal protective equipment (PPE). Facility has a Covid-19 Mitigation Plan, which was approved on 08/06/2021. West Sacramento Fire Department conducted a fire inspection on 12/08/2021 and found no violations.
There were 2 residents in care at the facility during this inspection.

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: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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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