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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804182
Report Date: 11/07/2023
Date Signed: 11/07/2023 04:00:16 PM

Document Has Been Signed on 11/07/2023 04:00 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:ARIA CARE HOMEFACILITY NUMBER:
486804182
ADMINISTRATOR:MALLARI, CRISTINAFACILITY TYPE:
740
ADDRESS:107 SANDPIPER DRIVETELEPHONE:
(707) 803-0654
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 4DATE:
11/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Cristina L. Mallari, AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst(LPA) Carol Fowler arrived to conduct a Pre-Licensing Inspection and was greeted by Applicant Cristina L. Mallari, Administrator current Administrator of Aria Care Home (RCFE). Component III orientation was completed with Administrator.

LPA and Administrator, conducted a walk through of the facility that will have 6 clients admitted once licensed. LPA observed the following: There was a supply of perishable and nonperishable food. There was a supply of water. Facility had a first aid kit, including the first aid guide book. Each private client room was furnished with all required items per regulation. Additional linens were available for use as needed. Bathroom had grab bars and non-slip flooring/mat for safety as needed. Hot water measured at 116.9 F which is between 105 and 120 F, per regulation. Facility has a backyard that includes a deck, in the for resident use. There is a ramp from the kitchen area slider that leads on to a covered porch which leads to the backyard, which is also the fire exit from the kitchen. Facility has enough dishes and cook ware to accommodate each client. Medications will be stored in a locked medication cart. Toxins/cleaners are stored in locked laundry room.

Facility has received a fire clearance approval from the local fire department dated 10/18/2023. Fire extinguisher, one (1), was purchased and tagged, as required, expires 12/01/2024. All smoke alarms, ten (10), combined with carbon monoxide detector, were all working properly during the inspection. Facility has a required infection control plan. Facility has an emergency disaster plan as required.

LPA will forward a copy of the prelicensing report to the application Analyst; The application Analyst will notify the applicants of the status of their application.

No deficiencies cited during inspection. A copy of this report provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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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