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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803941
Report Date: 05/26/2022
Date Signed: 05/26/2022 10:42:02 AM

Document Has Been Signed on 05/26/2022 10:42 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Licensee, Victor DadaTIME COMPLETED:
10:51 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee, Victor Dada. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA rang the doorbell at the gate multiple times and called the Licensee. LPA waited for approximately thirty minutes until Licensee answered the phone. LPA discussed concerns with Licensee regarding wait times, specifically if residents were able to alert staff if they needed assistance during the night. LPA confirmed that the doorbell on the gate does work and the alert goes to the Licensee's phone. LPA suggested turning up the phone or using a different device. Caregiver showed LPA the motion detector that is used in the resident's room in case they get up in the night and is loud enough to alert staff.

LPA observed Covid posters on the front door. Once inside, LPA observed a screening station near the entrance along with a visitor sign in. LPA confirmed with caregiver that they are screening all visitors. Facility is not currently conducting vaccine verification noting that there is only one person who visits. LPA directed caregiver to verify vaccination status of all visitors per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility at around 8:55 am and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected once per day.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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: ASHKALON HOUSE
FACILITY NUMBER: 496803941
VISIT DATE: 05/26/2022
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Continued from LIC809

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff have conducted PPE training but have not been N95 fit tested. LPA and Licensee discussed visitation and activities.

Facility has submitted and CCL 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, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Facility has hardwired combination smoke and carbon monoxide detectors throughout facility that were tested and operational. Fire extinguishers were last serviced April 2022.

Licensee and LPA discussed their Emergency Disaster Plan as well as the Infection Control Plan (PIN 22-13) that is due June 30, 2022.



Licensee/Administrator to submit updates of the following documents by 6/26/2022:

LIC 308 Designated Administrator
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Residents
Liability Insurance

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

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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