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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803930
Report Date: 02/28/2022
Date Signed: 02/28/2022 03:15:23 PM

Document Has Been Signed on 02/28/2022 03:15 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: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:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Chuluunchimeg Young TIME COMPLETED:
03:30 PM
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At approximately 2:00PM, Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced to conduct an Annual inspection visit and was greeted by Staff Member, Uranchimeg Tumurbaatar. The inspection is focused on the Infection Control procedures and practices of this facility. Administrator, Chuluunchimeg Young arrived later during the visit.

Upon arrival at the facility, LPAs had their temperatures checked and logged. LPAs conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and Hand-washing signs were observed in the bathrooms and at sinks. Observed staff were wearing masks. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPAs observed laundry detergent in the laundry room that was unlocked and accessible to residents. LPAs discussed with Administrator that laundry detergent needs to be in a locked cabinet even if the residents at facility do not have dementia.

All staff have received training on infection control. Facility has a cleaning and disinfecting schedule that occurs once per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for clients. Staff and Residents are screened daily for COVID-19 symptoms and it is logged into facility binders.

Continued on LIC-809C.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2022
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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Document Has Been Signed on 02/28/2022 03:15 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 02/28/2022 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: A&C CARE
FACILITY NUMBER: 486803930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation the licensee did not comply with the section cited above by having laundry detergent accessible to residents in care. This poses an immediate health and safety risk to residents in care.
POC Due Date: 03/01/2022
Plan of Correction
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Administrator immediately placed laundry detergent in a locked cabinet. POC cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022


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: A&C CARE
FACILITY NUMBER: 486803930
VISIT DATE: 02/28/2022
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Continued on LIC-809.

Fire Extinguisher is to be serviced in March 2022. Facility opened last year and has not had them serviced yet. Carbon Monoxide detectors and Smoke Alarms were tested and operational during this visit.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022
LIC809 (FAS) - (06/04)
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