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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804008
Report Date: 11/21/2024
Date Signed: 11/21/2024 02:11:51 PM

Document Has Been Signed on 11/21/2024 02:11 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:ALF SANCTUARY ADULT RESIDENTIAL CAREFACILITY NUMBER:
486804008
ADMINISTRATOR/
DIRECTOR:		MARIA BUNAFACILITY TYPE:
740
ADDRESS:521 SARAH WAYTELEPHONE:
(559) 303-7020
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 6CENSUS: 6DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Maria Buna, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Staff 1 (S1) and Staff 2 (S2). Administrator, Maria Buna was contacted via telephone and arrived at approximately 10:50 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. All residents were present during today's inspection. Facility has a hospice waiver for two (2), an exception for an additional hospice resident currently, a bedridden waiver for one (1), and is approved for all non-ambulatory residents.

At approximately 10:30 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in Residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of hygiene products, clean linens, paper products, and incontinent care briefs available for residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a covered seating area in the backyard with outdoor space for activities. Facility has internet available to residents in care and the phone was tested an operational. Residents have their own internet access devices.

Facility's fire extinguishers were observed charged and was last serviced 9/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills with the most recent drill conducted 9/2024. LPA observed facility's infection control plan and emergency disaster plan which was last updated 11/2024.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ALF SANCTUARY ADULT RESIDENTIAL CARE
FACILITY NUMBER: 486804008
VISIT DATE: 11/21/2024
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Continued from LIC809...

LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights for emergency preparedness. Administrator provided LPA with a copy of the facility's current liability insurance.

At approximately 11:30 AM, LPA reviewed five (5) staff files and six (6) resident files. Five (5) of five (5) staff files reviewed have all of the required paperwork and proof of current First Aid and CPR training. Six (6) of six (6) resident files reviewed have all the required paperwork. Administrator and residents' families coordinates medical and dental visits for the residents and transportation to and from their appointments. Facility has a podiatrist who comes to the facility for residents regularly.

At approximately 1:15 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. Facility does not manage P&I for residents.

No deficiencies were cited during inspection.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 Personnel Report (updated)

Exit interview conducted with Administrator whose signature on form confirms receipt of documents.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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