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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804108
Report Date: 02/03/2023
Date Signed: 02/03/2023 09:27:20 AM

Document Has Been Signed on 02/03/2023 09:27 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:ANGEL'S PLACE IN MOSSWOOD PLACEFACILITY NUMBER:
496804108
ADMINISTRATOR:DICHOSO, ALMAFACILITY TYPE:
740
ADDRESS:311 MOSSWOOD LANETELEPHONE:
(707) 708-2694
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 5DATE:
02/03/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:Alma Dichoso (Licensee)TIME COMPLETED:
09:42 AM
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Licensing Program Analyst (LPA) Cuadra arrive unannounced for the purpose of conducting Post-Licensing inspection visit and met with Licensee Alma Dichoso.

LPA/Licensee toured the facility inside and outside. Facility is a one story building. The facility was inspected and found to be clean and in good repair at the time of the inspection with all exits free from obstruction. Fire Extinguishers were charged and serviced as of January 2023. All auditory alarms, Smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the inspection. Hot water temperature measured at 118.2 degrees in resident's bathrooms which is within regulation. Resident records, personnel records, medication and toxins were locked and inaccessible to resident's in care. Facility has first aid kit which was found to be appropriate during the Post-Licensing inspection. There is outdoor space for activities. All resident’s bedrooms have lighting & appropriate furnishings, and resident’s beds were outfitted with mattress pads as required by Title 22 Regulations.

Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility does perform daily screening of staff and residents and documents it. Facility is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE and have been N95 fit tested. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer.

No deficiencies were cited during this Post-Licensing inspection. Exit interview was conducted, and a copy of this report was signed and given to the Licensee.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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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