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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804042
Report Date: 02/13/2023
Date Signed: 02/13/2023 03:43:37 PM

Document Has Been Signed on 02/13/2023 03:43 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:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Alma Corsiga, Administrator. TIME COMPLETED:
03:53 PM
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Licensing Program Analyst (LPA) Karina Canela arrived for the purpose of conducting a Required -1 Year inspection and met with Alma Corsiga, Administrator. Currently, the facility does not have any residents in care.
The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. LPA toured the facility, all exits were unobstructed, and the facility was found to be clean & at a comfortable temperature. Facility has a COVID-19 screening station. Fire extinguisher was charged. The facility has a supply of PPE. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. There are 10 hardwired smoke detectors and 1 carbon monoxide detector, which were tested & observed operational. The facility has submitted their Infection Control Plan to the California Department of Social Services, Community Care Licensing.
All staff wore face masks during this visit.

LPA requested the following updated forms to be submitted to Community Care Licensing by 03/13/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Liability Insurance
· LIC 610E Emergency Disaster Plan
· Copy of current Administrator's Certificate
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2023
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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