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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804207
Report Date: 03/05/2024
Date Signed: 03/05/2024 11:54:11 AM

Document Has Been Signed on 03/05/2024 11:54 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:PERLA'S PLACEFACILITY NUMBER:
236804207
ADMINISTRATOR:GONZALEZ, PERLAFACILITY TYPE:
740
ADDRESS:144 FAIRVIEW PLTELEPHONE:
(707) 972-5831
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 6CENSUS: 0DATE:
03/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Perla GonzalezTIME COMPLETED:
12:10 PM
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 announced, for the purpose of completing a pre-licensing evaluation. LPA met with Applicant Perla Gonzalez and toured the facility. The facility is a 6-bedroom, 3-bathroom, single story house. Fire extinguishers were mounted and charged. Smoke detectors were tested and in working order. 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 6 of 6 rooms. Hot water temperature was tested and found to be within regulation between 105 degrees F and 120 degrees F at faucets accessible to residents.

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's 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.

Applicant stated the Liability insurance agent is ready to issue insurance upon receipt of the License.

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: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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