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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803505
Report Date: 05/09/2022
Date Signed: 05/09/2022 03:02:06 PM

Document Has Been Signed on 05/09/2022 03:02 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:TAKING THE JOURNEY LLCFACILITY NUMBER:
496803505
ADMINISTRATOR:DOSS, KISAFACILITY TYPE:
740
ADDRESS:512 CASA VERDE CIRCLETELEPHONE:
(707) 981-8751
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 6DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 AM
MET WITH:Licensee/Administrator Kelly EriksenTIME COMPLETED:
03:01 PM
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Licensing Program Analysts (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcomed by staff Elia Cuevas. Licensee Kelly Eriksen arrived during the visit. There were 6 residents present at the facility, 2 on hospice.

LPA arrived at the facility and had temperature checked. All staff temperatures checked and logged each shift. LPA toured the facility with staff Elia Cuevas. During tour on 5/9/2022 facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 4/27/2022 at the time of the visit. A sample of 1 out of 1 Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility staff understands that food stored in the kitchen refrigerator must be properly stored as per regulations. Hot water temperature measured 113.7 degrees F and 117 degrees F within acceptable regulations of 105 to 120 degrees F in 2 of 2 resident’s bathroom faucets. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings.

Infection Control:
Facility has submitted a mitigation program plan that was approved on 6/27/2021. Posters have been placed at facility. Facility has PPE supply stored in Hallway closet. Residents’ medications are centrally stored and locked in the office file cabinet. Facility has a 30-day supply of medication for residents. Residents do not wear masks inside the facility. Facility offers activities of Tai Chi, Indoor gardening, walks, and bingo for the residents.

In addition, facility has a designated area for visitors in the backyard, living room, and/or in the bedrooms when possible. Residents have also available Zoom and telephone calls when contacting with family members and others. Staff had all PPE training required on file and all have been N-95 fit tested.



Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TAKING THE JOURNEY LLC
FACILITY NUMBER: 496803505
VISIT DATE: 05/09/2022
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LPA reviewed Licensing Information System (LIS) with licensee who stated that is corrected and updated at this time. In addition, LPA advised facility to contact County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.


LPA was presented with proof of CPR & 1st Aid certification for staff which files were reviewed.
Administrator Certificate’s for Kisa Doss # 6022355740 Exp. 3/7/2023 & Kelly Eriksen #6027539740 Exp. 11/4/2023
All staff have received COVID booster vaccinations and exclusively work at this facility.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 5/27/2022 to SRRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC809 (FAS) - (06/04)
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