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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803575
Report Date: 03/25/2025
Date Signed: 03/25/2025 02:33:26 PM

Document Has Been Signed on 03/25/2025 02:33 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:HOLY SPIRIT RESIDENTIAL CARE HOME-IIIFACILITY NUMBER:
236803575
ADMINISTRATOR/
DIRECTOR:
PERLA AND GENARO GONZALEZFACILITY TYPE:
740
ADDRESS:414 GROVE STREETTELEPHONE:
(707) 367-1586
CITY:WILLITSSTATE: CAZIP CODE:
95490
CAPACITY: 6CENSUS: 6DATE:
03/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Belen SedanoTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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At approximately 1:45PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Caregiver Belen Sedano and explained the purpose of the visit. Administrator certificate is current. Facility has a Hospice waiver for 6 residents.

At approximately 1:55PM, LPA toured the facility to ensure the health and safety of residents in care. The facility was observed to be at a comfortable temperature. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The kitchen contained cooking/dining equipment that was clean and orderly, utensils were present. Food appears to be stored and prepared properly. Refrigerators and freezers were maintained in an orderly fashion. Facility has required seven-day non-perishable and two-day perishable supply of food. Facility has a generator to supply power in an emergency. Emergency lighting devices were present.

Due to time constraints, LPA will return at a later date to review resident and staff records.

No citations issued during this visit.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Christopher Arnhold
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
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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