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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804042
Report Date: 02/15/2022
Date Signed: 02/15/2022 03:22:41 PM

Document Has Been Signed on 02/15/2022 03:22 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:BICKFORD HOMEFACILITY NUMBER:
486804042
ADMINISTRATOR:CORSIGA, ALMAFACILITY TYPE:
740
ADDRESS:5083 BICKFORD CIRCLETELEPHONE:
(707) 344-2628
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
02/15/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Alma Corsiga, ApplicantTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Karina Canela conducted an initial pre-licensing inspection and met with applicant Alma Corsiga who will be the Administrator once the facility is approved for licensure. The facility has a fire clearance approval from the Fairfield Fire Department of 2 ambulatory and 2 non-ambulatory, for a total capacity of 4 residents. The facility does not have a fire clearance approval to accept or retain bedridden residents. The facility has an approved Hospice Waiver for 2 residents and a Dementia Care Plan within their Plan of Operation. Facility will operate with live-in staff and Licensee will ensure sufficient staffing at all times.

During today’s visit LPA observed the following items:
· COVID-19 screening station with visitor log.
· Lockable separate cabinets for medications, toxins/cleaners, and knives.
· All exits were unobstructed
· 10 hardwired smoke detectors, which were tested and observed operational
· 1 carbon monoxide detector, tested and observed operational
· Complete first Aid kit, night-lights, and flashlights for emergency lighting
· Supply of paper products available
· Grab bars in the bathroom.
· Fire Extinguisher charged
· The water temperature was tested during inspection and was within regulation of 105-120 Degrees F.
Report continued on LIC 809-C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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: BICKFORD HOME
FACILITY NUMBER: 486804042
VISIT DATE: 02/15/2022
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Component III orientation was completed with the applicant during this inspection.

    Pre-licensing is incomplete with corrections needed
    The following corrections are needed to proceed with the application process:
      · Required posting: CCLD complaint poster (PUB 475) in the required size 20" x 26"
      · Chest of drawers in resident bedroom #4
      · Tagged fire extinguisher with current service date
      · Extra linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, and pillow cases...the quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times.
Applicant to provide pictures of the corrected items as proof of correction to LPA Canela. Once LPA receives the corrections, LPA will submit the pre-licensing application report and corrections to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of the application status.

No deficiencies cited.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
LIC809 (FAS) - (06/04)
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