<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804158
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:19:02 AM

Document Has Been Signed on 12/14/2023 11:19 AM - 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) 357-4547
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: 4CENSUS: 1DATE:
12/14/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Jessica GrinbergTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a Post Licensing visit. LPA met with Administrator Jessica Grinberg, toured the facility and reviewed records.
At approximately 8:45AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerator and freezer were clean, and food was stored properly. Toxins are stored in a locked closet in the hallway. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were tied into the fire system and found to be in working order. Carbon Monoxide detector was present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and locked.
At approximately 9:30AM, LPA reviewed 1 of 1 resident records and found resident to have physician's reports, signed admission agreements, care plans and physician's orders on file. Medication records are thorough and contained physician's orders. At approximately 10:00AM, LPA reviewed 2 of 2 on duty staff records which contained documentation of current first aid and CPR training. 1 of 2 staff records did not contain evidence of required annual training. Administrator informed LPA the staff is up to date in training but the documents are at their other facility. At approximately 10:45AM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternate meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency.
No citations issued during this visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1