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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803941
Report Date: 09/23/2021
Date Signed: 09/23/2021 04:01:34 PM

Document Has Been Signed on 09/23/2021 04:01 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:ASHKALON HOUSEFACILITY NUMBER:
496803941
ADMINISTRATOR:DADA, VICTOR C.FACILITY TYPE:
740
ADDRESS:912 DETURK AVE.TELEPHONE:
(707) 478-7411
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 2DATE:
09/23/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Licensee, Victor DadaTIME COMPLETED:
04:15 PM
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Licensing Program Analyst Willis arrived unannounced to conduct a Post Licensing Inspection and met with Licensee, Victor Dada.

Upon arrival, LPA's temperature was checked and documented and LPA was asked to sign in. LPA conducted a walk-through of the facility and observed the following: Facility has Covid-19 posters throughout the facility including on the front door and hand washing signs in the bathroom. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was available in common areas. Staff wear masks while in the facility. Observed staff had masks on during this visit. Per conversation with Licensee, they are not currently screening residents and staff daily but will start.

LPA and Administrator discussed resident activities and visitation. Commonly touched surfaces are disinfected throughout the day.

Facility was recently licensed so does not currently have a Mitigation Plan but will complete an LIC808 form and submit to CCL no later than October 8, 2021. Facility has at least a 30 day supply of Personal Protective Equipment (PPE) including surgical masks, gloves and hand sanitizer. LPA suggested getting N95 masks, gowns and face shields in case facility has a Covid positive resident in the future. Licensee will look into N95 fit testing in case it becomes needed. Facility maintains a 30 day supply of medication.

LPA requested that Licensee review PIN 21-43-ASC regarding Mitigation Plans and PIN 21-40-ASC regarding Visitation, Testing And Vaccination Verification.



Administrator and LPA discussed their Emergency Disaster Plan.
.
No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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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