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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803882
Report Date: 12/19/2022
Date Signed: 12/19/2022 06:37:56 PM

Document Has Been Signed on 12/19/2022 06:37 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: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: 4DATE:
12/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Art Villegas, Licensee/AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Canela arrived unannounced, to conduct an Annual Required 1 YR inspection and was greeted by care staff, Licensee/Administrator, Art Villegas, arrived a few minutes later. The inspection is focused on the Infection Control procedures and practices of this facility

Upon arrival, LPA observed that facility has Covid posters on the front door. LPA discussed visitation procedures with administrator, documenting & screening questions. Once inside the facility, LPA observed that facility has a sign-in for visitors, screening area with PPE . 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, and paper towels. Facility was a comfortable temperature. Residents are encouraged to wear masks when in the community. Commonly touched surfaces are disinfected throughout the day.
Facility staff have been trained on PPE Facility has submitted their Covid-19 Mitigation Plan and has 30 day supply of Personal Protective Equipment and (PPE) is in a location that is stored and accessible to staff. Facility maintains a 30 day supply of medication.

LPA received a fire clearance approval on 11/29/2022 from the Benicia Fire Department for facility to use bedrooms 1-4 for 6 non-ambulatory residents and bedroom #5 to be used as office and it is not permitted to be used as a bedroom or for sleeping purposes. Facility will have awake staff and there is no approval for bedridden resident rooms. Fire Extinguisher was observed charged, with no tag of service. LPA requested facility to acquire tag of service and send to LPA Canela.


Continue report See LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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: CASA ISABELLA II
FACILITY NUMBER: 486803882
VISIT DATE: 12/19/2022
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LPA requested the following updated records to be submitted to Community Care Licensing by 1/15/2023

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond, if applicable
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current, updated facility Sketch
· Copy of Liability insurance
· Copy Administrator Certificate


Exit interview conducted with Art Villegas, Licensee/Administrator.
No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC809 (FAS) - (06/04)
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