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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801786
Report Date: 10/29/2021
Date Signed: 11/03/2021 10:24:05 PM

Document Has Been Signed on 11/03/2021 10:24 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ANGEL'S CREST HOMEFACILITY NUMBER:
486801786
ADMINISTRATOR:FABIE, MARIVIEFACILITY TYPE:
740
ADDRESS:258 DARLEY DRIVETELEPHONE:
(707) 644-3687
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 6DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:Marivie FabieTIME COMPLETED:
03:09 PM
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Licensing Program Analyst (LPA) Canela arrived unannounced, to conduct an Annual Required inspection and was greeted by care staff, Administrator, Marivie Fabie arrived a few minutes later. The inspection is focused on the Infection Control procedures and practices of this facility. LPA conducted risk assessment upon arrival to facility. Administrator and LPA discussed the Emergency Disaster Plan.
Upon arrival, LPA observed that facility has Covid posters on the front door. LPA discussed visitation procedures with administrator, documenting & screening questions. Once inside the facility, LPA observed that facility has a sign-in for visitors, screening area but failed to take LPAs temperature . LPA observed that staff were wearing masks during today's visit. LPA conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms, but no paper towels. Facility was a comfortable temperature and LPA requested facility to clean sliding doors, so that they may open easily. Hand sanitizer was observed throughout the facility. Residents are encouraged to wear masks when in the community. Commonly touched surfaces are disinfected throughout the day. All residents have their own private room and may be isolated if the need arises.
Facility staff have been trained on PPE protocols but have not yet been N-95 fit tested. Facility has submitted their Covid-19 Mitigation Plan and it was approved on 8/20/2021. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is in a location that is stored and accessible to staff. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate of staff and residents.

LPA provided the following guidance: Get staff N-95 fit tested, request for postural support for resident R1, Remove bed from garage storage room area. Facility stated no one sleeps in the garage and understands, unless approved by the fire department, no one may sleep in any other area of the home unless it is a bedroom approved for sleeping.
No deficiencies cited during today's inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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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