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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801786
Report Date: 11/04/2022
Date Signed: 11/07/2022 12:25:44 PM

Document Has Been Signed on 11/07/2022 12:25 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: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:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Marivie FabieTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Canela arrived unannounced, to conduct an Annual Required 1 YR 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

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 with PPE . 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. 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 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.

LPA consulted regarding the backyard deck wood rails that need to be secured, firm and in good condition. LPA went over resident R1 who has a small sofa in her room instead of a regular bed. LPA and Administrator discussed requirements and doctors note required for review of R1s room and paperwork needed to review for request of approval.

Continue report See LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ANGEL'S CREST HOME
FACILITY NUMBER: 486801786
VISIT DATE: 11/04/2022
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LPA requested the following updated records to be submitted to Community Care Licensing by 11/22/2022

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond, if applicable
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current, updated facility Sketch
· Copy of Liability insurance
· Copy Administrator Certificate
· Copy of Admission Agreement


Exit interview conducted with Marivie Fabie, Licensee/Administrator.
No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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