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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126804231
Report Date: 09/16/2024
Date Signed: 09/16/2024 01:46:43 PM

Document Has Been Signed on 09/16/2024 01:46 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:CARING COMPANIONS CARE HOME IIFACILITY NUMBER:
126804231
ADMINISTRATOR/
DIRECTOR:
RASMUSSEN, COLLEENFACILITY TYPE:
740
ADDRESS:3014 HARRIS STTELEPHONE:
(707) 444-2211
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY: 6CENSUS: 0DATE:
09/16/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Colleen RasmussenTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived announced to conduct a Pre-licensing Facility Inspection. LPA met with Applicant Colleen Rasmussen. Facility has received fire clearance for six residents, four of which may be Non-Ambulatory and one may be bedridden. Facility has included Dementia Care in the Plan of Operation but will not be advertising for dementia. Facility is a single-story, four bedroom, two bath home. Night lights were present in the hallways. Grab bars and nonskid mat were present in each bathroom. Beds were made with appropriate linens. Resident rooms contained the required furniture in 4 of 4 rooms. Hot water temperature was within regulation. Medications will be centrally stored and locked. Kitchen appliances, utensils, and food preparation areas are in good condition. There is secure storage for knives. Stove knobs have locking devices when not in use. Toxins and cleansers are secured. Fire extinguishers were charged. All exits have functional auditory alarms. Smoke detectors were tested and in working order. Carbon Monoxide detector was present and operational. Applicant has quotes for Liability insurance and will secure a policy when the License is granted.

Component III orientation was conducted at facility. Applicant conveyed a good knowledge of Title 22 regulations.

The pre-licensing evaluation has been completed. LPA will submit the application packet for a final review and approval from the Licensing Program Manager.

This report was reviewed with applicant and a copy was provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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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