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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 575001806
Report Date: 11/03/2022
Date Signed: 11/03/2022 02:55:17 PM


Document Has Been Signed on 11/03/2022 02:55 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: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: 4DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Juliet Dugyon, AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted 1 year required inspection, focused on the Infection Control procedures and practices of this facility. Administrator/Licensee Juliet Dugyon participated via phone.
There were two caregivers at the facility at the time of inspection.

LPA toured the facility with carestaff and residents on 11/03/2022 at approximately 1:45 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 upon return from outings or when they exhibit symptoms. All information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins and sharps for the kitchen are stored and locked in laundry room. There was adequate dry food for at least a week and fresh foods for at least 2 days. All food was stored appropriately and dated. Medications were stored in locked medication closet making them inaccessible to residents and staff that do not handle medications. The medications were well-organized and stored in labeled containers with the residents' names and photos. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Each bathroom had soap and paper towels. 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 and Infection Control Plan. The fire extinguisher was serviced on October 16, 2022. The carbon monoxide detector was tested and operational. The facility has a central fire alarm system.
There were 4 residents in care at the facility during this inspection.

No deficiencies during today's inspection.
No citations issued.
Exit interview conducted with the Administrator, and signed by care giver for Administrator (who was off site).
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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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