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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803064
Report Date: 02/23/2023
Date Signed: 02/23/2023 09:57:15 AM

Document Has Been Signed on 02/23/2023 09:57 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: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: 6DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Lot Santos (Manager Staff)TIME COMPLETED:
10:12 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Manager staff Lot Santos. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by staff for Covid-19 which included a temperature check and signing in. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least three times per day. Facility continues to screen staff and residents and maintains documentation. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE and have been N95 fit tested. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Facility has submitted their Emergency Disaster Plan, Infection Control Plan and Mitigation Plan. Fire extinguisher is fully charged and serviced within the last year. Smoke detectors and carbon monoxide were tested and found operational. LPA was informed by Manager during the visit there is another certified Administrator Sheila Sumabat on duty as well. LPA discussed and requested the following documents to change Administrator on file.
Administrator agreed to submit the following by 3/6/2023: LIC215 Applicant Information, LIC 500 Personnel Summary, LIC 308 Designated Administrator, LIC 501 Personnel Record, Administrator Resume, Copy of current Administrator certificate, copy of Personal ID, Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations), LIC 610 Emergency Disaster Plan (review and update if changes), Liability Insurance and lease agreement.
No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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