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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803693
Report Date: 11/09/2021
Date Signed: 11/09/2021 11:52:01 AM

Document Has Been Signed on 11/09/2021 11:52 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:WAYNE HOMEFACILITY NUMBER:
486803693
ADMINISTRATOR:MONTECLAR, IRENEFACILITY TYPE:
740
ADDRESS:909 CALLE DEL CABALLOTELEPHONE:
(650) 703-1217
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 4DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Irene Monteclar & Licensee Kevin Braud TIME COMPLETED:
11:51 AM
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At 10:10 AM Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection of this facility. Upon arrival LPA was greeted by John Ednalaga, Direct Support Professional. Danica Ednalaga, Caregiver arrived 10 minutes later from shopping. Licensee Kevin Braud arrived 10 minutes after that. Ms. Ednalaga contacted Irene Monteclar, Administrator to inform them of LPA's presence. Ms. Ednalaga was given authority to proceed with the licensing inspection with Licensee Braud until the Administrator arrived.

At 10:37 AM LPA began tour of facility, hallway and passageways leading to exits were free of obstruction and facility temperature was comfortable. Hot water temperature measured 119.6 degrees F. and 116.7 degrees F. within range of 105 degrees and 120 degrees F in bathroom faucets accessible to residents. Smoke and carbon monoxide detectors were tested and found working. Fire extinguishers last serviced/charged on 7/6/2021 were mounted in the hallway and laundry room. Toxins were stored locked under the kitchen sink and in the laundry room. Sharps were observed to be locked in a kitchen drawer. LPA observed the garage to be accessible by residents. Toilet and shower areas were clean and sanitary. Resident’s requiring special feeding supplies have designated closets or cabinets where their supplies are stored separately. Ample supply of hygiene products were stored in a cabinet in the garage. Perishable and non-perishable food supply met the minimum requirements for current census. Refrigerator and freezers were clean and food was stored properly. Medications centrally stored are locked in a cabinet located in the living room. Small locked refrigerator is used for medications requiring refrigeration located in the garage. Facility has incorporated a recreational therapist for residents each week along with a variety of activities and or zoom with day programs.

Continued on LIC 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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: WAYNE HOME
FACILITY NUMBER: 486803693
VISIT DATE: 11/09/2021
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Infection Control:
Facility has submitted a mitigation program plan that has been approved 6/1/2021. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in each bedroom, front office area, and garage. Facility has a 30-day supply of medication for residents. Residents are not 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.

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

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills have been conducted quarterly with the last one being conducted on 10/20/2021. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1st Aid certification for staff.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 11/23/2021 to RPRO:

LIC 308 Designated

LIC 400 Affidavit Regarding Cash Resources

LIC 402 Current Surety Bond

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
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