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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803693
Report Date: 10/24/2022
Date Signed: 10/24/2022 02:27:31 PM

Document Has Been Signed on 10/24/2022 02:27 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:WAYNE HOMEFACILITY NUMBER:
486803693
ADMINISTRATOR:MONTECLAR, IRENEFACILITY TYPE:
740
ADDRESS:909 CALLE DEL CABALLOTELEPHONE:
(650) 703-1217
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 4DATE:
10/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Facility Manager, Danica Ednalaga
Administrator, Irene Monteclar
Licensee, Kevin Braud		TIME COMPLETED:
02:45 PM
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License Program Analyst (LPA) Farhaan Sarangi arrived unannounced to conduct a Required – 1 year inspection at Wayne Home. LPA was welcomed by Facility Manager, Danica Ednalaga and was granted access into the facility. Administrator arrived 10 minutes later.

LPA began touring the facility with the House Manager and Administrator. LPA observed the hallway and passageways leading to exits were free of obstruction and facility temperature was comfortable. Hot water temperature measured 116.7 degrees F. and 116.7 degrees F. within range of 105 degrees and 120 degrees F in bathroom faucets accessible to residents. Smoke and carbon monoxide detectors were tested and found to be operational during the inspection. Fire extinguishers last serviced/charged on July 2022 were mounted in the hallway and laundry room. Toxins were stored locked under the kitchen sink and in the laundry room. Sharp knives were observed to be locked in a kitchen drawer which is inaccessible to residents in care. Toilet and shower areas were clean and sanitary. Resident’s requiring special feeding supplies have designated closets or cabinets where their supplies are stored separately. Ample supply of hygiene products were stored in a cabinet in the garage. Perishable and non-perishable food supply met the minimum requirements for current census. Refrigerator and freezers were clean and food was stored properly. Medications centrally stored and locked in a cabinet located in the living room. Small locked refrigerator is used for medications requiring refrigeration located in the garage. First Aid kit was inspected and found to be appropriate during the inspection.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the garage. Facility has been N95 Fit tested on March 2022.

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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: WAYNE HOME
FACILITY NUMBER: 486803693
VISIT DATE: 10/24/2022
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LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator due to printer issues.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC809 (FAS) - (06/04)
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