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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803392
Report Date: 07/16/2021
Date Signed: 07/16/2021 12:16:49 PM

Document Has Been Signed on 07/16/2021 12:16 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:AVALON CARE HOME IIFACILITY NUMBER:
486803392
ADMINISTRATOR:ATWAL, PRITPAL K.FACILITY TYPE:
740
ADDRESS:5082 RASMUSSEN WAYTELEPHONE:
(707) 386-1042
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Pritpal Atwal, AdministratorTIME COMPLETED:
12:27 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Pritpal Atwal, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

LPA observed a screening station at the entrance of the facility which had a thermometer, hand sanitizer, and a sign-in sheet for staff and visitors. LPA documented her name and temperature. LPA discussed with Administrator documenting a COVID-19 questionnaire. Visitors temperatures are taken upon arrival to the facility. Staff and Resident's temperatures are taken and documented twice daily. LPA conducted a walk-through of the facility with Administrator and observed COVID-19 precaution postings. Administrator stated staff clean and disinfect the facility and high touched surface areas daily. The facility has a designated visitation area, offers virtual visits and phone calls for family to stay in contact with residents.

LPA observed 5 residents in care. Facility staff training on PPE use, isolation policies, and infection prevention is in progress. N-95 respirator Fit testing (Cal/OSHA requirement) is in process. LPA observed a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and gowns. All staff wore a face mask during this visit.
The facility has a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19, which was submitted to the California Department of Social Services for review.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.

No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2021
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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