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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803392
Report Date: 06/20/2022
Date Signed: 06/20/2022 01:45:14 PM

Document Has Been Signed on 06/20/2022 01:45 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: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: 6DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Pritpal "Meenu" Atwal, AdministratorTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Administrator Pritpal "Meenu" Atwal. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

LPA toured the facility and observed 6 residents in care. Facility has a COVID-19 screening station (visitor sign-in sheet, COVID questionnaire, thermometer, hand sanitizer). Staff have current CPR/first aid certifications. Fire extinguisher was charged and bought new on 1/22/2022 (LPA observed receipt). The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff and Resident's temperatures are taken daily and documented. Staff clean and disinfect the facility throughout the day. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms.

The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing.
During this visit, LPA verified staff vaccination records for COVID-19.

Report continued on LIC809-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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: AVALON CARE HOME II
FACILITY NUMBER: 486803392
VISIT DATE: 06/20/2022
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LPA discussed the following requirements with Administrator:
· Facility to obtain N-95 mask fit testing for staff (Cal/OSHA requirement) - Technical Advisory Note was issued to the facility during this visit.
· Auditory Alarms must be on to monitory exits


LPA requested the following updated forms to be submitted to Community Care Licensing by 07/11/2022:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of liability insurance
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current Administrator's Certificate
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
· Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475). The poster that is posted shall be 20" x 26"
·Administrator to send vaccine verification to LPA for staff's vaccine records that were not in file.
· Provide copies of physician's order for bed rail that extends from the head half the length of the bed to be used only for assistance with mobility for (R1 & R2)

Reminder: Infection Control Plan due 06/30/2022

Exit interview conducted with Meenu Atwal, Administrator, whose signature on this document confirms receipt. Due to printer issues, this report was emailed

No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
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