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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803882
Report Date: 12/07/2021
Date Signed: 12/08/2021 11:18:28 AM

Document Has Been Signed on 12/08/2021 11:18 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:CASA ISABELLA IIFACILITY NUMBER:
486803882
ADMINISTRATOR:VILLEGAS, ART GFACILITY TYPE:
740
ADDRESS:680 SNAPDRAGON PLTELEPHONE:
(707) 344-0839
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY: 6CENSUS: 5DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Art VillegasTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection at approximately 1:45 PM, and met with, Administrator, Art Villegas. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA toured facility and grounds with care staff and observed COVID-19 precaution signs posted in common areas to promote hand washing and physical distancing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. LPA consulted with facility and explained, facility needs to follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test within 72 hours. Facility states staff clean and disinfect the facility daily. Facility understands hand sanitizer should not be placed in the rooms of residents who lack hazard awareness and impulse control. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was submitted to the department on 3/8/2021. Caregivers have completed PPE training but have not been N-95 Fit tested.
In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be charged and serviced 3/2/2021. Smoke and Carbon monoxide detectors were fully operational. At time of inspection, there was sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. LPA provided additional PPE to facility at end of visit.

LPA requested the following update to be submitted to CCL Rohnert Park by 12/22/2021: scheduled appointment for N95 Fit testing; Fire clearance verification/city permit; copy of plan of operation and admission agreement regarding cameras in common areas.
Exit interview conducted with Administrator. No deficiencies cited during this inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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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