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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804221
Report Date: 05/07/2024
Date Signed: 05/07/2024 12:46:59 PM

Document Has Been Signed on 05/07/2024 12:46 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PLEASANT VALLEY CARE HOMEFACILITY NUMBER:
216804221
ADMINISTRATOR/
DIRECTOR:
BAUTISTA, BRIAN W.FACILITY TYPE:
740
ADDRESS:20 MCKEON CT.TELEPHONE:
(415) 895-1604
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 0DATE:
05/07/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Applicants, Anabelle Bautistia and Brian BautistaTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived announced to conduct a Pre-Licensing Inspection and met with Applicants, Anabelle Bautista and Brian Bautista. Upon arrival, LPA was informed that there are currently no residents in care. Facility received an approved fire clearance dated 01/04/2024 that allows for six non-ambulatory clients. Facility also has a hospice waiver for 2 individuals.

LPA conducted a walk-though of facility with Applicants and observed the following: Facility is a one story residence with five resident bedrooms, two bathrooms and common areas. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. All resident rooms were furnished per regulation with a bed, lamp, dresser, chair and bedside table. Facility has sufficient items for cooking and eating. Facility has a locked cabinet in the hallway used for centrally stored medications and files. Cleaning supplies and toxins will be locked in a cabinet in the garage. Facility has indoor/outdoor areas for visiting and activities. Facility has emergency lighting in hallways. LPA confirmed that contents of the facility First Aid Kit were sufficient.

LPA confirmed that Applicants is familiar with Guardian. Component III was reviewed.

No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Residential Care Facility for the Elderly.

LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status.

Exit interview conducted. Copy of report discussed and provided. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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