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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803639
Report Date: 11/05/2021
Date Signed: 11/05/2021 02:23:33 PM

Document Has Been Signed on 11/05/2021 02:23 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:PEOPLE'S CARE CHARMIANFACILITY NUMBER:
496803639
ADMINISTRATOR:SEAWRIGHT, PATRICKFACILITY TYPE:
740
ADDRESS:5087 CHARMIAN DRTELEPHONE:
(951) 775-7411
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 4CENSUS: 3DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator, Patrick SeawrightTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year Inspection at approximately 1:20 PM, and met with administrator Patrick Seawright. The inspection was focused on the Infection Control procedures and practices of this facility.

Upon entry administrator screened LPA for COVID symptoms and asked LPA to sign-in on visitor sheet. At primary entrance LPA observed visitor logs and COVID screening sheets. LPA conducted walk through of the facility with administrator. Facility was a comfortable temperature and exits were free from obstructions. Mitigation plan has been submitted and reviewed by Community Care Licensing (CCL).

Hand sanitizer is kept throughout the facility. Staff have completed Personal Protective Equipment (PPE)/infection control training. Administrator indicated they have received training to N95 fit test staff. High touch surface areas are disinfected daily. Facility has private bedrooms therefore clients could isolate if necessary in their own bedrooms. Facility has necessary PPE and supplies to support a resident in isolation. All staff and clients are vaccinated. Facility tests one staff a week on rotating basis. There are a total of four staff.

Clients' emergency contact information has been updated and staff confirmed they are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked laundry room cabinet and in a closet located in the bathroom. Medications are centrally stored in a locked cabinet making them inaccessible to residents.

LPA requested updated copies of the following documents: LIC 308, LIC 400, LIC 500, LIC 9020, Emergency Disaster Plan, Liability Insurance, and Administrator Certificate

No deficiencies observed during today's inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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