Senior Care Records.

Facility Evaluation Report

Hickory House, San Rafael12/22/2022Licence 216800419

Capacity6
Census6
Date signed12/22/2022 01:16:26 PM
The inspector’s account

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 12/22/2022 to conduct a required 1-year inspection. This inspection was focused on the infection control practices and procedures of this facility. LPA conducted inspection with lead staff, Danny Mclane. Administrator was notified of LPA arrival.

LPA observed necessary COVID postings and screening materials at the front entrance. LPA toured building and grounds which were clean and in good repair. Exits and walkways were free from obstructions. LPA observed sufficient perishable and non perishable food. Medications were locked and secured. Toxins were locked and secured. Clients attend day programs. Staff will encourage clients to practice good mask etiquette. There were extra hygiene supplies and fresh linens available for clients. Fire extinguishers inspected were charged and current. Carbon monoxide detectors were present. Staff monitor clients for symptoms. Staff have been provided with infection control training. LPA observed Personal Protective Equipment available to support a client in isolation.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this inspection:

LIC400 Affidavit Regarding Client Cash Resources

Exit interview conducted with staff and a copy of this report emailed to the administrator.

Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction