216801993-6-8-2021-21-AS-SHAN-C3SQC7-20210608120240

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801993
Report Date: 06/08/2021
Date Signed: 06/08/2021 04:26:27 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:	CICADA-MILL VALLEY		FACILITY NUMBER:	216801993
ADMINISTRATOR:	NOEL CAMATOG		FACILITY TYPE:	735
ADDRESS:	309 ENTERPRISE CONCOURSE		TELEPHONE:	(415) 888-3880
CITY:	MILL VALLEY	STATE: CA	ZIP CODE:	94941
CAPACITY:	6	CENSUS: 6	DATE:	06/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Daniel Limpin -staff		TIME COMPLETED:	12:15 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 Analysts (LPAs) Fernandes-Goes & Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff Daniel Limpin. Clients were present at the facility due to COVID-19. Facility has 4 clients that day program has zoom activities, and 2 clients have no day program at this time. Facility has other activity plans for clients during the day. LPAs arrived at the facility and observed hand sanitizer at the entrance; temperatures were checked at arrival. Facility has a log in binder for temperature of clients and visitors. During facility tour on 6/8/2021 with staff Daniel; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 03/2021 at the time of the visit. Smoke Detectors & Carbon monoxide detector was found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility staff understands that food stored in the kitchen refrigerator must be properly stored as per regulations. Toxins are stored in a locked laundry room. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings, mattress pads are available for clients at the facility. Infection Control: Facility has submitted a mitigation program plan that has been approved at this time. Posters have been placed at facility and entrance has sanitizer designated for visitors and staff before coming into work. Facility has very small PPE supply stored in the hallway closet by entrance. Facility has not hired or admitted anyone new since COVID-19. Clients’ medications are stored and locked in hallway closet. Facility has a 30-day supply of medication for clients. Clients aren’t wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Continue LIC 809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

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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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: CICADA-MILL VALLEY	FACILITY NUMBER: 216801993
	VISIT DATE: 06/08/2021

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In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Clients have also available zoom and telephone calls when contacting with family members and others. Staff had all PPE training required on file and still working towards acquiring N-95 fit testing.

LPAs reviewed Licensing Information System (LIS) with staff who stated that is corrected and updated at this time. In addition, LPA advised facility to contact Marin County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted every six months with the last one being conducted on 1/8/2021.

There were no deficiencies cited at this time.

LPAs are requesting licensee to update the following documents by 06/15/2021 and submit to the Department Regional Office in Rohnert Park:

LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
Copy of Control of Property/Lease Agreement

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC809 (FAS) - (06/04)

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