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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804158
Report Date: 07/24/2023
Date Signed: 07/24/2023 12:28:18 PM

Document Has Been Signed on 07/24/2023 12:28 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:LOTTE'S HOUSEFACILITY NUMBER:
236804158
ADMINISTRATOR:GRINBERG, JESSICAFACILITY TYPE:
740
ADDRESS:346 E. CYPRESS STTELEPHONE:
(707) 964-4940
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: 4CENSUS: 0DATE:
07/24/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jessica GrinbergTIME COMPLETED:
12:45 PM
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At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility for the purpose of completing a pre-licensing evaluation. LPA met with Applicant Jessica Grinberg and toured the facility. The Facility is a 4-bedroom, 3-bathroom, single story house. Fire extinguisher was mounted and charged. Smoke detectors are facility wide and tied to the sprinkler system. There was a locked area for medications and several for toxins and cleaning supplies. Beds were made with appropriate linens. Resident rooms contained the required furniture in 4 of 4 rooms. Hot water temperature was tested and found to be within regulation between 105 and 120 degrees F. Exit doors had working alert devices installed. Carbon monoxide detectors were present.

This facility has submitted a request for a hospice waiver and a plan to care for residents with dementia. The plan has been reviewed and all physical plant safeguards have been checked. The applicant states that they do not plan to advertise at this time. A fire clearance for this facility has been granted.

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

LPA received evidence of Liability insurance during visit.

Facility is ready to be Licensed. LPA will submit the application packet for a final review and approval from the Licensing Program Manager.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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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