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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803595
Report Date: 12/05/2023
Date Signed: 12/05/2023 04:25:44 PM

Document Has Been Signed on 12/05/2023 04:25 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:
12/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:24 PM
MET WITH:Melanie & RusselTaningco-CaregiversTIME COMPLETED:
04:30 PM
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Licensing Program Analyst(LPA) Alviso conducted Required-1 Year inspection and met with live-in caregivers Melanie and Russel Taningco. Administrator Josephine Blancaflor arrived to the facility within the hour to meet with the LPA.

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 has a required infection control plan.

The LPA toured the facility with the caregivers. All exits were clear and unobstructed. All smoke alarms were working properly during the inspection; The facility has a carbon monoxide detector that was working properly during the inspection. Two fire extinguishers were serviced and tagged as required. Toxins/cleaners were locked up making them inaccessible to residents in care. Medications were locked up making them inaccessible to residents in care. The hot water was checked at 118.7 degrees Fahrenheit.

The LPA will complete the annual inspection at a later date.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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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