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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803337
Report Date: 02/08/2022
Date Signed: 02/08/2022 03:03:21 PM

Document Has Been Signed on 02/08/2022 03:03 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:BUCKINGHAM RESIDENTIAL CARE HOMEFACILITY NUMBER:
496803337
ADMINISTRATOR:MARTINEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:954 BUCKINGHAM DRIVETELEPHONE:
(707) 888-5259
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 5DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Caregiver, Evelyn TadlasTIME COMPLETED:
03:15 PM
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Licensing Program Analysts (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with caregiver, Evelyn Tadlas. Licensee/Administrator, Angelica Martinez was unable to come to the facility but was briefly available by phone. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed posters outside notifying visitors to not come in if not feeling well. A caregiver permitted LPA in but did not initially screen them and then left to get another caregiver. The second caregiver, Evelyn Tadlas arrived and indicated that the Licensee was not available. LPA called Licensee who confirmed that they would not be available and gave permission for a caregiver to sign the report. LPA requested caregiver to walk them through their screening process. Caregiver checked LPA's temperature and requested that a questionnaire with standard Covid-19 screening questions be filled out. LPA asked caregiver if they verify vaccination for visitors and they indicated that the residents do not get visitors. LPA asked if the facility was not allowing visitation and the caregiver said they were allowing visitation but most families called on the phone. LPA notified caregiver that they must verify vaccination for visitors who want to visit inside or confirm they have a negative Covid test within 72 hours. LPA initiated a walk-through of the facility around 2:00 pm and observed the following: Facility has COVID-19 posters throughout that includes hand washing signs in bathrooms. Hand sanitizer is located throughout common areas of the facility and in resident rooms. Other hand-washing supplies were also observed in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Observed staff had masks on during this visit. LPA asked caregiver how often commonly touched surfaces were being disinfected and they indicated that they disinfect each morning, evening and after use. Facility maintains documentation of staff and resident daily temperatures.

Continued on LIC809
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: BUCKINGHAM RESIDENTIAL CARE HOME
FACILITY NUMBER: 496803337
VISIT DATE: 02/08/2022
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Continued from LIC809

Facility has a designated visitation area outside. Per Licensee, staff have completed PPE training and have been N95 fit tested, however, caregivers were unable to provide documentation to LPA.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has some Personal Protective Equipment (PPE) including masks, gloves, gowns, face shields and hand sanitizer but does not have any N-95s. Facility does not have a 30 day supply of all items. Facility maintains a 30 day supply of medication.

Fire extinguishers were last serviced October 2021. Smoke alarms throughout the facility and Carbon Monoxide detector were tested and operational.


No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC809 (FAS) - (06/04)
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