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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803930
Report Date: 08/27/2021
Date Signed: 08/27/2021 01:31:10 PM

Document Has Been Signed on 08/27/2021 01:31 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:A&C CAREFACILITY NUMBER:
486803930
ADMINISTRATOR:YOUNG, ALEXFACILITY TYPE:
740
ADDRESS:5144 DARTMOOR CIRCLETELEPHONE:
(415) 812-1517
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 6CENSUS: 1DATE:
08/27/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alex Young and Chuluunchimeg Young, AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Lopez arrived unannounced to conduct a Post Licensing inspection on 8/27/21. LPA conducted a risk assessment prior to visit. LPA was greeted by staff and Administrators, Alex Young and Chuluunchimeg Young arrived later for the visit. LPA toured the building and grounds.

LPA toured the facility and was found to be at a comfortable temperature with all exits free from obstruction. Resident bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were new and fully charged. Administrator showed proof of Fire Extinguisher purchase date of 4/15/21 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly. Water temperature was tested and measured within regulation of 105-120 degree F. LPA verified that the facility’s medications are kept locked and inaccessible to resident. Toxins are stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available.

Posters have been placed at entrance, and facility entrance area has a designated area to screen visitors, thermometer and other items designated for visitors and staff before coming into work. Facility has a 30-day supply of PPE. Facility has a 30-day supply of medication for residents. Facility has conducted staff training on infection control.


No deficiencies issued during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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