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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830786
Report Date: 11/22/2022
Date Signed: 11/22/2022 11:59:46 AM

Document Has Been Signed on 11/22/2022 11:59 AM - 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:OUR LADY OF PEACE HOME CAREFACILITY NUMBER:
486830786
ADMINISTRATOR:CABE, ROMEOFACILITY TYPE:
740
ADDRESS:900 DAWNVIEW WAYTELEPHONE:
(707) 447-1920
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 4DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Romeo CabeTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Our Lady of Peace Home Care for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Administrator, Romeo Cabe, and was granted access into the facility.

LPA toured the building and grounds with the Administrator and observed the facility to be clean and a comfortable temperature of 73 degrees F. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for 6 residents in care. Food was found to be stored in a safe manner. Water temperature measured at 110 degrees F in both residents bathrooms, which is within regulation between 105 and 120 degrees F in faucets used by residents. There was an ample supply of linens, cleaners, hygiene products and paper products available for residents. Toxins were inspected and are located in a locked cabinet under the kitchen sink and in a cabinet in the laundry room. All resident's bathrooms contained necessary grab bars and non-slip floors/mats. Medication is centrally stored in a locked closet in the resident hallway. All bedrooms are equipped with lighting and proper bedding which was clean and in good repair. Fire extinguishers were last inspected August 2022. Smoke detectors located throughout the facility were tested and operational during the inspection. Carbon monoxide detector was observed in the dinning area and in working order. Exit doors have auditory alert system that was functional at time of inspection. LPA observed an installed fire pull system with wired auditory and visual alarms throughout the facility. Last emergency drill was conducted on October 2022.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the bedroom walk-in closet. Facility is N95 Fit tested in September 2022.

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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: OUR LADY OF PEACE HOME CARE
FACILITY NUMBER: 486830786
VISIT DATE: 11/22/2022
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`LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator due to printer issues.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
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