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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804182
Report Date: 10/31/2024
Date Signed: 10/31/2024 03:08:02 PM

Document Has Been Signed on 10/31/2024 03:08 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/
DIRECTOR:		MALLARI, CRISTINAFACILITY TYPE:
740
ADDRESS:107 SANDPIPER DRIVETELEPHONE:
(707) 803-0654
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Cristina Mallari, Administrator
Rogie Mallari, Licensee		TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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10/31/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 5 residents in care. Facility approved/cleared for 6 ambulatory, 3 non-ambulatory, and 1 bedridden. Waiver/Granted for hospice care for 3. LPA was greeted at front door by staff member. Upon arrival LPA observed two staff members on shift. Administrator, Cristina Mallari arrived shortly after. Licensee, Rogie Mallari arrived later during visit.

At approximately 1:00pm, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 114.2 and 114.6 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected Aug, 2024. Facility conducts fire drills quarterly with the last fire drill being conducted on 08/24/2024. Toxins, sharps and other items that could pose threat if available to residents were located in a drawer in the kitchen and were found to be secured. Extra cleaning products are stored in a locked pantry. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

LPA conducted review of 4 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.


continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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: ARIA CARE HOME
FACILITY NUMBER: 486804182
VISIT DATE: 10/31/2024
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LPA conducted a review of 4 resident records. All records had the required documentation.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC309- Administrative Organization
Infection control plan (review, update if any changes)
Updated Emergency disaster plan

Exit interview conducted with Administrator and a copy of this report was provided.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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