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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801807
Report Date: 07/09/2021
Date Signed: 07/09/2021 01:01:16 PM

Document Has Been Signed on 07/09/2021 01:01 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:YERBA BUENA RESIDENTIAL CARE HOMEFACILITY NUMBER:
496801807
ADMINISTRATOR:MARTINEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:5200 YERBA BUENATELEPHONE:
(707) 539-6780
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 6DATE:
07/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Staff, Elida MendozaTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos and Licensing Program Manager (LPM) Kimberley Mota arrived unannounced to conduct an Annual inspection at approximately 12:00 PM, and met with staff Elida Mendoza. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPA and LPM were asked to fill out a screening form and sign in. At primary entrance LPAs observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with Elida Mendoza and observed COVID postings throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL).

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per staff, updated infection control guidelines and PINs are communicated to staff verbally. Staff have completed Personal Protective Equipment (PPE) and infection control training through Kaiser. High touch surface areas are disinfected daily. Due to residents having private rooms they could isolate in their own rooms if they became ill. LPA and LPM confirmed facility has necessary PPE equipment and supplies to support a resident in isolation.

Residents' emergency contact information has been updated and staff indicated they are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked hallway closet and in locked cabinets under the kitchen and bathroom sinks. A 30 day supply of medications are locked in administrator's office. The facility has a sufficient supply of Personal Protective Equipment (PPE) located in administrators office. All exit alarms on exit doors were working properly. Facility is conducting COVID-19 surveillance testing per CCL guidelines. All staff have been vaccinated

Continued on LIC 809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: YERBA BUENA RESIDENTIAL CARE HOME
FACILITY NUMBER: 496801807
VISIT DATE: 07/09/2021
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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Some residents also prefer to have meals in their rooms. Common areas are also set up for social distancing. Visits are occurring both inside the facility as well as on the outdoor patio area. Staff confirmed if residents were to go on outings they would be screened for symptoms on their return.


No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
LIC809 (FAS) - (06/04)
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