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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804178
Report Date: 01/18/2024
Date Signed: 01/18/2024 12:31:18 PM

Document Has Been Signed on 01/18/2024 12:31 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:TIMELESS CARE, INC.FACILITY NUMBER:
486804178
ADMINISTRATOR:ZAMORA, VALJOSEPHFACILITY TYPE:
740
ADDRESS:1494 QUAIL DRIVETELEPHONE:
(408) 509-3786
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 0DATE:
01/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Valjoseph "Jo" Zamora, Licensee ApplicantTIME COMPLETED:
12:30 PM
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On 1/18/2024 Licensing Program Analyst (LPA) Tobola conducted a pre-licensing inspection and was greeted by Licensee Applicant, Valjoseph Zamora. This pre-licensing inspection is being conducted for an initial licensing. The facility is a single story building with 6 bedrooms and a granted fire clearance approved for 2 ambulatory and 4 non-ambulatory residents.

LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean and comfortable temperature with bedroom doors free from obstruction. Fire extinguisher located in the kitchen was found to be last charged on 12/23/2023. Smoke detectors and carbon monoxide detectors were tested in common areas and client bedrooms all of which were found to be in working order. Emergency exits along the one side of the facility have appropriate hardware and found to be unobstructed. Water was measured at 144.6 degrees F in faucets used by residents which does not fall within regulation between 105 & 120 degrees F. Licensee Applicant agrees to ensure compliance and submit a water record log for correction.

There was an ample supply of linens with appropriate bedding equipped in client rooms. An additional supply of hygiene, continence and paper products are located in a secured cabinet in hallway. Stairs and hallways are equipped with several night lights for accessibility and client bedrooms have appropriate furnishings. There is a sufficient amount of dishes and cooking supplies for client use with sharps and other hazardous items kept secured in designated drawer and under the kitchen sink. Cleaning products and other toxins and chemicals are kept out of client access and found secured in the garage and laundry room cabinets and under kitchen sinks. LPA observed adequate supply of both perishable and non-perishable food sufficient for the 6 residents in care. The facility will be conducting weekly grocery replenishment with consideration to client preferences and dietary restrictions. A sample menu is also located on the refrigerator and indicates a healthy and balance set of meals for residents in care.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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: TIMELESS CARE, INC.
FACILITY NUMBER: 486804178
VISIT DATE: 01/18/2024
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Medications are centrally stored and secured in a locked closet located near front corridor with Centrally Stored Medication Records and several other medication related forms ready for file. All staffing records and resident specified files including care plans, medical reports and dietary restrictions will also be located in this storage space.

Program operation documentation, emergency disaster information and licensing form templates pertaining to resident and staff rights have also been posted in the front of the facility. The facility has begun the hiring process for direct care giving staff and have appropriate criminal record and transfer forms readily available.

The backyard features a large yard and deck with seating for client outdoor use. The facility will be including additional recreational items based on client preference upon admission. Windows, screens and blinds are all found to be in good repair. There is a working telephone and internet device available for resident use. Emergency evacuation maps and clear exit signs are observed posted at each exit door. Infection control plan to be updated and protocol infection prevention information will be available upon licensing. A sign in sheet with proper screening devices and protection equipment were also observed in the living room. The facility and facility operation plan are found to be adequate and tour of the facility completed.

The Licensee Applicant is to provide the following items:
- 7-Day water temperature log for resident restrooms
- photo of auditory alarm sensor in resident bedroom #1
- photo of emergency evacuation map at sliding all exits
- Infection control plan

All items to be submitted to CCLD by POC date1/31/2024


Licensee will be sending a copy of the updated liability insurance to CCLD. Component III orientation was conducted with the Licensee Applicant. The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager. This report was reviewed with applicant and a copy was provided to the Licensee.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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