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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803691
Report Date: 09/07/2023
Date Signed: 09/07/2023 12:57:02 PM


Document Has Been Signed on 09/07/2023 12:57 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ADELAIDE HOMEFACILITY NUMBER:
486803691
ADMINISTRATOR:MARIA SICKMENFACILITY TYPE:
735
ADDRESS:615 CHRISTINE DRIVETELEPHONE:
(415) 990-9617
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:4CENSUS: 4DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Virgilyn Cervantes, Nurse(RN)TIME COMPLETED:
01:45 PM
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Licensing Program Analysts (LPA) Carol Fowler arrived to conduct a Required-1 Year visit, on 9/7/2023 at approximately 9:00am, and met with Nurse Virgilyn Cervantes and Imelda Mendaros Lead DSP. There are currently fore (4) clients in care. All one (1) of fore (4) clients are at Disney Land with Administrator.

Fire clearance is approved for fore (4) non-ambulatory. Facility has a required Infection Control Plan. Facility has an Emergency Disaster Plan as required. Per record review, last fire drills, fire & evacuation, were held on 9/1/2023.

LPA reviewed fore (4) staff files. All staff had required criminal record clearance. All staff had required annual training. All staff had current first aid, and CPR certification. All staff files were complete. LPA reviewed fore client files. All client files were complete.

LPA toured the facility with the Nurse and Lead DSP. Hot water ws checked at 115.3F. The facility had a sufficient food supply. The facility had a sufficient supply of hygiene products, cleaners/disinfectants, and paper supplies. All cleaners/disinfectants were locked and inaccessible to clients in care. All medications were locked and inaccessible to clients in care. Fire extinguishers, two(2) were serviced and tagged as required. The eight (8) smoke alarms/carbon monoxide detectors were all working properly when checked during the inspection; All exits were clear and unobstructed.

LPA requested the following forms be submitted by 9/15/23:
Personnel Report
Designation of Responsibility
Affidavit Regarding Client Cash Resources
Copy of Surety Bond
Emergency Disaster Plan
Control of Property

There are no deficiencies cited today. Exit interview and a copy of this report provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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