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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801225
Report Date: 12/08/2022
Date Signed: 12/08/2022 01:52:37 PM

Document Has Been Signed on 12/08/2022 01:52 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:VICTORIA'S PLACEFACILITY NUMBER:
496801225
ADMINISTRATOR:MEJIA-CHISTIAKOFF,CONCHITAFACILITY TYPE:
740
ADDRESS:2300 DONAHUE AVE.TELEPHONE:
(707) 843-0341
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 5DATE:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee Orr ChistiakoffTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection and met with Licensee, Orr Chistiakoff. Facility currently has 5 residents, one with Dementia and none on hospice.

LPA observed that facility has posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms. Facility was a comfortable temperature and free from obstructions. Resident rooms were furnished per regulation. Extra hygiene products and linens were available. Water temperature in resident's bathroom measured at 107 degrees F. to 113.3 degrees F. which are within allowable range of 105 to 120 degrees F. Bathrooms had required bathmats and grab bars. Hand sanitizer is kept in the common area and throughout the facility. Facility has multiple bathrooms that are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least one time a day. Facility has designated an outdoor area for visitation. All residents are located in single rooms in case that they need to isolate and is able to serve meals and deliver medications. Cleaning supplies stored under kitchen sink and in outside laundry room were inaccessible to residents in care. Knives and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Required postings were observed. Menus posted. Facility staff have been trained on PPE protocols, all staff have been N-95 fit tested. Facility maintains a 30 day supply of medication. Activities had been reduced to more outdoor areas to prevent the spread of the virus. Residents have access to alternative communications as phone calls and video calls with their families.

Continue on LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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: VICTORIA'S PLACE
FACILITY NUMBER: 496801225
VISIT DATE: 12/08/2022
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Infection Control:

Fire extinguisher was last inspected 1/31/2022. Smoke detectors and carbon monoxide detector located throughout the facility were tested and operational. Exit doors have auditory alert system and were functional at time of visit. Last Disaster drill was conducted on October 15, 2022.

Facility has submitted their Covid Mitigation Plan and Infection Control Plan w/ Monkey Pox. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields, gowns and hand sanitizer. PPE supplies are located in an accessible place for all staff.

LPA was presented with proof of current CPR & 1st Aid certification for staff.



Administrator Certificate is for Conchita Mejia-Chistiakoff #6001288740 Exp. 3/28/2023

Administrator/Licensee agreed to submit the following documents by 12/22/22:

Designation of Responsibility (LIC308)

Lease agreement, liability insurance

Personal Report (LIC500)

Resident List (9020)

No deficiencies observed during today's visit.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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