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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803731
Report Date: 05/19/2021
Date Signed: 05/19/2021 11:31:19 AM

Document Has Been Signed on 05/19/2021 11:31 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LAS PALMAS ASSISTED LIVINGFACILITY NUMBER:
496803731
ADMINISTRATOR:PRICE, THOMASFACILITY TYPE:
740
ADDRESS:218 N HIGH STREETTELEPHONE:
(707) 583-5895
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 6CENSUS: 6DATE:
05/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Josephine Blancaflor (Licensee)TIME COMPLETED:
11:45 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Licensee, Josephine Blancaflor. LPA conducted a Risk Assessment call with Licensee prior to the visit. There were 6 residents in care present at the facility.

LPA arrived at the facility and had her temperature checked and logged into a sign-in sheet that included screening of symptoms. LPA/staff conducted a tour through the facility and observed facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Kitchen Cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Fire Extinguisher was found to be last charged on 07/2020 at the time of the visit. Smoke Detectors & Carbon monoxide detector were found to be operational during the visit. Exit doors have auditory alert system that were functional at time of visit.

Facility has submitted a mitigation program plan that has been approved on 1/20/2021. Posters have been placed at entrance, and facility entrance area has a designated area to screen visitors, thermometer and other items designated for visitors and staff before coming into work. Staff and residents are being screened and monitored daily and results are documented in a binder for each month. Facility has PPE supplies stored in the storage bin. Facility has a 30-day supply of medication for residents. Residents do not typically wear masks inside the facility but have them available. Facility has a designated outdoor visitation area. Facility has conducted staff training on infection control.

Licensee submitted updates of the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) Liability insurance, Lease Agreement and Emergency Disaster Plan (LIC610E).

No deficiencies were cited during today's inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2021
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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