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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803935
Report Date: 11/15/2021
Date Signed: 11/15/2021 02:50:39 PM

Document Has Been Signed on 11/15/2021 02:50 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:L & A RESIDENTIAL CARE HOMEFACILITY NUMBER:
486803935
ADMINISTRATOR:BAUTISTA, ROMULO N JRFACILITY TYPE:
740
ADDRESS:455 JERRYLEE ROADTELEPHONE:
(510) 750-2003
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 3DATE:
11/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:Caregiver, Leilani GambolTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and was greeted by caregivers. Administrator, Romulo Bautista was available by phone and LPA received permission from them to have caregiver, Leilani Gambol sign report. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by caregiver and screening was documented. LPA initiated a walk-through of the facility with caregiver around 2:00pm and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms and general Covid-19 information at the front entrance. LPA confirmed with caregiver that they are conducting vaccine verification for visitors per Provider Information Notice (PIN) 21-40-ASC. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility and in some bathrooms. Other hand-washing supplies were also observed in bathrooms. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day and after use. Facility maintains documentation of staff and resident daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms. Staff have completed PPE training but have not been N95 fit tested. LPA discussed getting staff fit tested with Administrator.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns and hand sanitizer. Facility maintains a 30 day supply of medication.

Caregiver and LPA discussed their Emergency Disaster Plan. Fire extinguishers have been serviced within the last year. Hardwired combination smoke/carbon monoxide alarm system was tested and operational during inspection.



No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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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