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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803781
Report Date: 01/27/2022
Date Signed: 01/27/2022 11:21:35 AM

Document Has Been Signed on 01/27/2022 11:21 AM - 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:ADELAIDE HOME IIFACILITY NUMBER:
486803781
ADMINISTRATOR:MONTECLAR, IRENEFACILITY TYPE:
740
ADDRESS:1155 MAHOGANY CTTELEPHONE:
(707) 207-3941
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
01/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kevin Braud, LicenseeTIME COMPLETED:
11:31 AM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Kevin Braud, Licensee. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.

LPA conducted a walk-through of the facility with Licensee and Lead nurse Pam Deleon. A screening station was observed at front entrance of facility which had hand sanitizer, a non-touch thermometer, and a sign-in sheet for visitors and staff. LPA was screened for COVID-19 symptoms and temperature was taken. All visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Staff verify visitor's vaccination status and a negative COVID test per PIN 22-04-ASC and State Public Health Officer Order dated 12/31/2021 (LPA verified documentation).
The facility has designated visitation areas, provides virtual visits and phone calls for family to stay in contact with residents. Staff and resident's temperatures are taken daily and documented. Staff clean and disinfect the facility throughout the day and LPA observed documentation of a cleaning/disinfection schedule for staff. Staff have documented completion on the following training: infection prevention, symptoms, transmission and PPE use. The facility has a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and disposable gowns. 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.
N-95 Fit testing for staff has been completed (LPA observed N-95 Fit test cards for all staff). LPA observed 4 residents in care participating in activities.
All staff wore masks during this visit.

Exit interview conducted with Licensee, 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: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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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