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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286802019
Report Date: 07/28/2022
Date Signed: 07/28/2022 12:23:15 PM

Document Has Been Signed on 07/28/2022 12:23 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:LINDA FALLS GUEST HOME 1FACILITY NUMBER:
286802019
ADMINISTRATOR:SACRO, NORBERTFACILITY TYPE:
740
ADDRESS:755 LINDA FALLS TERRACETELEPHONE:
(707) 963-1440
CITY:ANGWINSTATE: CAZIP CODE:
94508
CAPACITY: 6CENSUS: 6DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Staff, Lino CaramatTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 07/28/2022 at approximately 9:30 AM to conduct a Required-1 Year inspection. Administrator, Norbert Sacro was not available during the inspection but was notified over the phone and agreed to have LPA perform inspection with staff. LPA met with staff, Lino Caramat. This inspection was focused on the infection control practices and procedures of this facility.

Upon arrival LPA signed in and had their temperature taken. LPA toured the facility with staff. Building and grounds were clean and in good repair. Facility was a comfortable temperature and exits were free from obstructions. Carbon monoxide detectors were observed throughout the facility. Fire extinguishers were last inspected on June 10, 2021, LPA provided technical assistance. Licensee will service any recently expired fire extinguishers. LPA and staff discussed the importance of ensuring items potentially harmful to residents are kept inaccessible, LPA provided technical assistance. LPA measured water temperature at 116 degrees F at faucets accessible to residents. LPA and staff discussed the importance of water being no greater than 120 degrees F and no lower than 105 degrees F at faucets accessible to clients, LPA provided technical assistance. LPA provided facility with a copy of a document detailing required annual training for staff. LPA observed COVID postings throughout. High touch surface areas are disinfected daily.

LPA requested the following documents be submitted to Community Care Licensing within 30 days:
LIC 500 Personnel Report, LIC 9020 Resident Roster, LIC 610 Emergency Disaster Plan for RCFE, LIC 308 Designation of Facility Responsibility, Staff CPR Cards, Infection Control Plan, Evidence of Liability Insurance

Exit interview conducted with staff, Lino Caramat and a copy of this report printed for the facility.
No deficiencies cited during today's inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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