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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803789
Report Date: 08/13/2021
Date Signed: 08/13/2021 02:48:38 PM

Document Has Been Signed on 08/13/2021 02:48 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:TEJADA CARE HOME LLCFACILITY NUMBER:
486803789
ADMINISTRATOR:MENDOZA, JOSEPHINE GFACILITY TYPE:
740
ADDRESS:1440 OAKWOOD AVETELEPHONE:
(707) 853-2916
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 6DATE:
08/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Josephine Mendoza (Licensee)TIME COMPLETED:
02:48 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced, to conduct an Annual Required inspection and was greeted by staff and Licensee, Josephine Mendoza arrived later. The inspection is focused on the Infection Control procedures and practices of this facility. LPA conducted risk assessment call with Licensee prior to the visit. Administrator and LPA discussed the Emergency Disaster Plan.

Upon arrival, LPA observed that facility has posters on the front door indicating that visitors are not allowed. LPA discussed visitation with licensee who stated that residents receive visits from their responsible party and there is a designated living room for visitation and are documenting screening questions. Once inside the facility, LPA observed that facility does have a sign-in for visitors and did screen LPA when they came in. LPA observed that staff were wearing masks during today's visit. LPA conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed throughout the facility. Residents are encouraged to wear masks when in the community. Commonly touched surfaces are disinfected throughout the day. Facility has a designated isolation apartment on the facility premises.

Facility staff have been trained on PPE protocols but have not yet been N-95 fit tested. Facility has submitted their Covid Mitigation Plan and it was approved on 7/28/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is in a location that is stored and accessible to staff. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate of staff and residents, but still conducting surveillance test. Per Licensee, she has reviewed latest PINs 21-32 ASC and 21-33 ASC.

LPA provided the following guidance: Get staff N-95 fit tested.

No deficiencies cited during today's inspection
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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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