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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803843
Report Date: 07/22/2021
Date Signed: 07/22/2021 02:53:59 PM

Document Has Been Signed on 07/22/2021 02:53 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:PROVIDENCE RESIDENTIAL CARE - LAKEHURSTFACILITY NUMBER:
486803843
ADMINISTRATOR:LEWIS-BARRETO, ANNABELLEFACILITY TYPE:
740
ADDRESS:409 LAKEHURST COURTTELEPHONE:
(707) 439-1816
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ruben Poblete, Licensee & Co-AdministratorTIME COMPLETED:
03:03 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Ruben Poblete, Licensee & Co-Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

The facility has a screening area with hand sanitizer, a thermometer, gloves, surgical masks and 2 sign-in binders (1 for staff & 1 for visitors) with COVID-19 questionnaires. Visitors and staff's temperatures are taken and screened for COVID-19 symptoms upon arrival to the facility.
Client's temperatures are taken and documented daily once per shift (3 times daily). LPA conducted a walk-through of the facility with staff and observed COVID-19 precaution postings. Staff clean and disinfect the facility and high touched surface areas during every shift and after use. The facility has a designated visitation area, provides virtual visits, and phone calls for family to stay in contact with clients.

LPA observed 3 clients in care. Facility staff have completed training on PPE use, isolation policies, and infection prevention. N-95 respirator Fit testing (Cal/OSHA requirement) is in process. LPA observed a supply of PPE including gloves, face shields/goggles, N-95 respirators, surgical masks and gowns. All staff wore a face mask during this visit.
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.

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: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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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