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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803759
Report Date: 07/29/2021
Date Signed: 07/29/2021 10:21:47 AM

Document Has Been Signed on 07/29/2021 10:21 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:NATASHA'S HOMEFACILITY NUMBER:
496803759
ADMINISTRATOR:GLENN VARGASFACILITY TYPE:
740
ADDRESS:3365 PETALUMA HILL RDTELEPHONE:
(650) 270-3030
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 3CENSUS: 3DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff, Marilen AzurTIME COMPLETED:
10:31 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and met with staff, Marilen Azur. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was asked to sign in and was screened for Covid-19 symptoms. LPA conducted a walk-through of the facility and observed Covid-19 posters throughout that included hand washing signs in restrooms and posters at entrances. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed throughout the facility. Per staff, clients are assisted with hand hygiene. Clients are not always able to tolerate wearing masks but staff are required to wear them while in the facility. LPA observed staff had masks on during this visit. Clients have their meals staggered at the the dining room table for social distancing. Common areas are also set up for social distancing. LPA and staff discussed client activities and visitation. Facility has a designated visiting area in the backyard. Caregivers have been provided PPE training. Facility has not yet had staff N-95 Fit tested. Commonly touched surfaces are disinfected throughout the day. Facility has submitted and the department has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. Facility maintains a 30 day supply of medication. Facility had an inspection done July 12, 2021 of their fire alarm system.

100% of clients and staff are vaccinated. Per PIN, facility may discontinue surveillance testing.

LPA discussed the Emergency Disaster Plan with staff and confirmed that staff on all shifts are able to drive the facility van.

LPA suggested that staff are trained on new Covid-19 guidance from the CDC. Current training materials are dated.



No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2021
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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