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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804064
Report Date: 06/17/2022
Date Signed: 06/17/2022 01:44:17 PM

Document Has Been Signed on 06/17/2022 01:44 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:ART OF HOMECAREFACILITY NUMBER:
486804064
ADMINISTRATOR:VILLEGAS, IMEEFACILITY TYPE:
740
ADDRESS:1060 FEATHER RIVER CTTELEPHONE:
(707) 372-1355
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 0DATE:
06/17/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Art VillegasTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPA) Katrina Walters conducted a pre-licensing inspection on 06/17/2022. LPA met with Applicants, Art and Imee Villegas. On 3/30/22 The facility was granted a fire clearance approval from the Vacaville Fire Department for a capacity of 6 non-ambulatory residents. Licensee will ensure sufficient staffing at all times.
The facility is one level with 5 bedrooms that may be used for residents, 2 bathrooms, Recreational room, living room, dining room, kitchen, medication cabinet, laundry room and Garage.

LPA toured the facility to ensure that COVID-19 protocols were in place and made the following observations: At the entrance of the facility, a sign in sheet was placed on the entry table for all visitors to sign-in and be screened. There was hand sanitizer and disposable mask available for visitors. COVID-19 test were available for visitors who were not able to show proof of vaccination or negative COVID test. Sanitation stations throughout the hallways. Signs were posted to encourage droplet precaution.

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SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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: ART OF HOMECARE
FACILITY NUMBER: 486804064
VISIT DATE: 06/17/2022
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LPA also toured the facility for environmental and physical plant safety and found that the facility was clean an comfortable temperature. Smoke and carbon monoxide detectors were tested and appeared to be operational. The fire extinguisher was last serviced 6/7/22. All exits were unobstructed. All interior exits had auditory alarms, that were turned on at the time of inspection. First Aid kit, night-lights, and flashlights for emergency lighting were available. Bedrooms were furnished with chairs, dressers and beds with padding and appropriate lighting. Bathroom's had grab bars and slip mats. Hand washing supplies and paper products were available. Water temperature in faucets used by residents measured at 106.1 and 106.3

LPA reviewed records with applicant which included: Administrator certificate, Administrator duty descriptions, training's, program plan, activities and Admission agreement. A space has been designated to ensure confidentially and store facility files. Resident and staff binders were found to be organized. The applicant submitted an emergency disaster plan, mitigation plan, dementia care plan that has been approved. Facility has submitted a request for liability insurance. A copy of the quote was provided, once licensed applicant will request to be insured. The following signs posted in the entry way: Residents right's to counsel, Let Us Know complaint poster, personal rights, and emergency disaster information. The Applicant has ordered the Ombudsman poster and will receive the poster after licensure.

LPA conducted a COMP III with applicant some of the following items were discussed: Administrator Qualifications, Reporting Requirements, Maintenance and Operation, Personal Accommodations, Criminal Background clearance, Acceptance and Retention, Restricted and Prohibited Health Care Conditions.

This pre-licensing is complete. LPA will submit the pre-licensing reports to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. A copy of the report was given to the Applicant.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
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