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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 572700714
Report Date: 02/01/2022
Date Signed: 02/01/2022 03:46:08 PM

Document Has Been Signed on 02/01/2022 03:46 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CAREWELL AT PISTACHIO LLCFACILITY NUMBER:
572700714
ADMINISTRATOR:PANTIG, PAULINFACILITY TYPE:
740
ADDRESS:1125 PISTACHIO COURTTELEPHONE:
(530) 759-2060
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 6CENSUS: 6DATE:
02/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Paulin Pantig, Administrator and
Benjamin Pulan, Caregiver
TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced 1 year required inspection and met with Administrator Paulin Pantig and Benjamin Pulan, Caregiver. The inspection is focused on the Infection Control procedures and practices of this facility.

All visitors, essential visitors, and staff are screened upon entry. Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility; all information is logged. Residents are screened and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature of 74 F with all exits free from obstruction. Toxins are stored in locked cabinets and in the locked laundry room. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored in locked cabinets in the kitchen making them inaccessible to residents and staff that do not handle medications. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment (PPE). Administrator and all staff and 1 visitor had a mask on during the LPA's inspection. There is an approved Fire Clearance and hospice waiver for six (6) residents. Mitigation plan was approved by the Department on 04/22/21. There were six (6) residents in care at the facility during this inspection.

No deficiencies during today's inspection.
No citations issued.
Exit interview conducted with Benjamin Pulan, Caregiver.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2022
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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