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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803064
Report Date: 02/18/2022
Date Signed: 02/18/2022 03:18:51 PM

Document Has Been Signed on 02/18/2022 03:18 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:RINCON VALLEY GARDENS IFACILITY NUMBER:
496803064
ADMINISTRATOR:DICHOSO, RAYMONDFACILITY TYPE:
740
ADDRESS:5220 LOCKWOOD DRIVETELEPHONE:
(707) 538-3667
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 4DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Lot SantosTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 1:30 PM, and met with licensee, Sheila Sumabat and administrator, Lot Santos. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPA was screened for COVID symptoms and asked to sign in by administrator. At primary entrance LPA observed visitor sign-in sheet. LPA conducted walk through of the facility with administrator and observed COVID postings throughout. Mitigation plan was submitted by licensee and reviewed by Community Care Licensing.

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per administrator, updated infection control guidelines and PINs are communicated to responsible parties through email. Staff have completed Personal Protective Equipment (PPE) and infection control training through Kaiser and licensee. Staff have been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census residents could isolate in their own rooms if they became ill. LPA observed necessary PPE to support a resident in isolation. Residents are screened twice a day for symptoms.

Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible to residents. Medications are centrally stored and inaccessible to residents. All staff have received their booster shot.

Continued on LIC 809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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: RINCON VALLEY GARDENS I
FACILITY NUMBER: 496803064
VISIT DATE: 02/18/2022
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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing.

LPA and administrator discussed PIN 22-07 during inspection.

LPA requested the following documents during the visit:

LIC 500
LIC 501
Admin Certificate
LIC 200-Application for change of administrator.
LIC 308
Liability Insurance
Emergency Disaster Plan
Administrator Certificate

No deficiencies cited during this inspection.

Exit interview conducted with administrator and licensee. A copy of this report was printed for the facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC809 (FAS) - (06/04)
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