<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803595
Report Date: 11/24/2021
Date Signed: 12/04/2021 01:19:13 AM

Document Has Been Signed on 12/04/2021 01:19 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CARRIAGE HOUSEFACILITY NUMBER:
496803595
ADMINISTRATOR:BLANCAFLOR, JOSEPHINEFACILITY TYPE:
740
ADDRESS:5695 CARRIAGE LANETELEPHONE:
(707) 303-7159
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 6DATE:
11/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Josephine Blancaflor-Licensee/AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Dina Alviso conducted 1 year required inspection and met with Licensee/Administrator Josephine Blancaflor. The inspection is focused on the infection control procedures and practices of this facility.

All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions, including providing proof of covid vaccination, are to be answered before being allowed to remain in the facility. All information is logged. Residents are screened and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents. All bathrooms had grab bars, and non-slip mat/flooring for showering/bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Administrator and two caregivers on duty were observed by the LPA to be wearing masks during the inspection. Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Mitigation plan was reviewed by the Department on 6/5/21. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden approval (room #1 only). There were six (6) residents in care at the facility during this inspection.
No deficiencies during today's inspection.
No citations issued.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1