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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803064
Report Date: 04/11/2024
Date Signed: 04/11/2024 01:34:24 PM

Document Has Been Signed on 04/11/2024 01:34 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:RINCON VALLEY GARDENS IFACILITY NUMBER:
496803064
ADMINISTRATOR/
DIRECTOR:		LOT SANTOSFACILITY TYPE:
740
ADDRESS:5220 LOCKWOOD DRIVETELEPHONE:
(707) 538-3667
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 5DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:59 AM
MET WITH:Lot Santos, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Christi Coppo and LPA Stefanie Mutialu arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Lot Santos. Facility contact information was reviewed.

At approximately 9:30am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 106.2 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 8/17/23. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted on April 5, 2024. Facility has a backup generator for use during a power outage.

LPA observed storage room in garage converted to an actual bedroom for staff. Admin provided copy of building permit from City of Santa Rosa. Permit #B19-2414 issued on 5/9/2019 for residential addition alteration. Building plans for conversion of garage storage room also provided. Admin explained that they physically brought updated facility sketch to CCL RO in 2019 along with copy of building permit, in order to notify CCL of garage conversion and initiate an updated fire clearance. Per LPA record review, updated facility sketch not in CCL facility file, most recent facility sketch date stamped 4/25/2013. Facility will submit updated sketch to CCL no later than 4/15/2024. CCL will follow up with request for fire clearance and then follow up with facility once STD850 is received.

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SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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: RINCON VALLEY GARDENS I
FACILITY NUMBER: 496803064
VISIT DATE: 04/11/2024
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At approximately 11:30am LPA conducted a review of five [5] resident records. All required documentation present.

At approximately 12:30pm LPA conducted review of four [4] staff records. All required documentation present.

Lot Santos Administrator Certificate 7024203740 expires 1/14/2025. All fees are current as of this time.

LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

No deficiencies cited during this inspection. Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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