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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803595
Report Date: 11/06/2024
Date Signed: 11/06/2024 04:49:42 PM

Document Has Been Signed on 11/06/2024 04:49 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:CARRIAGE HOUSEFACILITY NUMBER:
496803595
ADMINISTRATOR/
DIRECTOR:
BLANCAFLOR, JOSEPHINEFACILITY TYPE:
740
ADDRESS:5695 CARRIAGE LANETELEPHONE:
(707) 303-7159
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 5DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Melanie Taningco-Live-in CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Alviso conducted Required-1 Year inspection and met with live-in caregiver Melanie Taningco. LPA observed a second caregiver working in the facility upon arrival. Administrator Josephine Blancaflor was contacted, and arrived within the hour to meet with the LPA.

There were five (5) 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. Facility has a required emergency disaster plan.

LPA toured the facility. Hot water was 114.6 degrees Fahrenheit, which is within regulation. Fire extinguishers (2) were serviced and tagged as required. All exits were clear and unobstructed. Facility was clean and orderly. Food supply was sufficient with both perishable and non-perishable foods; LPA observed lots of fruit on the kitchen counter which is used for residents meals and snacks. LPA observed dinner being prepared, lasagne, salad, cut up watermelon. Resident rooms, bathrooms, hallways, and common areas had sufficient lighting for residents in care. Facility has replaced the slider doors, and are having the slider doorway bottoms worked on to have no safety hazards when coming in or out of the slider doors. All disinfectants/cleaners were locked and inaccessible to residents in care. All medications were locked and inaccessible to residents in care. The facility was at a comfortable temperature. There was a sufficient supply of hygiene products, linens, cleaners/disinfectants, personal protective equipment (PPE), and paper products.

The annual will be continued at a later date.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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