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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803666
Report Date: 08/07/2023
Date Signed: 08/07/2023 03:06:04 PM

Document Has Been Signed on 08/07/2023 03:06 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:CASA ISABELLAFACILITY NUMBER:
486803666
ADMINISTRATOR:VILLEGAS, IMEE CFACILITY TYPE:
740
ADDRESS:3060 DUKE CIRCLETELEPHONE:
(707) 398-7539
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 3DATE:
08/07/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Imee VillegasTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Casa Isabella for the purpose of conducting a Case Management-Annual Continuation. LPA was greeted at the door by Caregiver, Myrna Santiago, and was granted access into the facility. Administrator arrived 10 minutes later.

During the Case Management-Annual Continuation, LPA reviewed 3 of 3 staff files and observed that 2 of 3 staff members did not have the annual training as outlined in Title 22 regulations (See LIC 9102-Technical Violation). LPA reviewed 4 of 4 resident records and found those to be appropriate during the inspection. 1 of 1 Medication Orders were reviewed. LPA interviewed 3 of 3 staff members. LPA interviewed 3 out of 3 residents in care. 1 resident is currently out of the facility at a doctors appointment.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + or any other infectious diseases in the facility. LPA discussed the Infection Control Plan with the Licensee/Administrator in detail. LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308-Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Liability insurance
Control of Property
Resident Roster

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
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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