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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803595
Report Date: 10/06/2022
Date Signed: 10/06/2022 02:46:19 PM

Document Has Been Signed on 10/06/2022 02:46 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: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:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Melanie Taningco-CaregiverTIME COMPLETED:
02:30 PM
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Licensing Program Analyst(LPA) Alviso conducted Required-1 Year inspection and met with caregivers Melanie and Alma. The inspection is focused on the infection control procedures and practices of this facility.

There are six (6) residents in care during the LPA's inspection. Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden approval (room #1 only).

Facility does have an infection control plan, and submitted a copy to the licensing office as required. LPA observed both staff were wearing masks as required. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Fire extinguishers, two (2), were serviced and tagged as required-expires 8/17/23. Toxins/cleaners are stored in locked cabinets making them inaccessible to residents in care. 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), for staff use, for residents if they want, and others as needed or required,

No deficiencies cited during today's inspection.
Exit interview conducted with Caregiver Melanie.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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