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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803759
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:41:32 PM

Document Has Been Signed on 08/13/2024 03:41 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:NATASHA'S HOMEFACILITY NUMBER:
496803759
ADMINISTRATOR/
DIRECTOR:
GLENN VARGASFACILITY TYPE:
740
ADDRESS:3365 PETALUMA HILL RDTELEPHONE:
(650) 270-3030
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 3CENSUS: 3DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Leonardo DeLa Cruz-AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:56 PM
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Licensing Program Analyst (LPA), Alviso is conducting an Required-1 Year inspection, on 8/13/24 at approximately 1:00pm, and met with Administrator Leonardo Dela Cruz. LPA observed two caregivers, Rolando and Josephine, on duty. The facility's nurse arrived during the LPA's inspection.

Currently three (3) residents in care. Facility has an approved fire clearance for three (3) non-ambulatory residents. All resident rooms are private. The facility does have a required infection control plan. The facility does have a required emergency disaster plan. Facility had a fire drill on 6/10/24 and an earthquake drill on 6/21/24, per record review.

LPA reviewed three (3) resident files. Files were complete. P&I monies were intact, not stored with any other facility funds/not commingled. All records of P&I were complete and maintained accurately.

LPA reviewed five staff files. All staff have first aid and CPR as required. All staff have criminal record clearance as required. Staff have required training.

Facility had a sufficient food supply. Medications were locked up and inaccessible to residents in care. Sufficient cleaners/disinfectants, paper products, hygiene products, and linens. Cleaners/disinfectants were locked up and inaccessible to residents in care. Facility had a sufficient supply of furnishings for resident use. All resident rooms, bathrooms, hallways, and common areas had sufficient lighting for resident use. The facility was observed to be at a comfortable temperature; Facility does have a heater system, and air conditioner unit for use as needed. There were emergency supplies, including food and water. The fire extinguishers were fully charged,two (2) in the facility. All exits and walkways were clear of obstruction. Sufficient personal protective equipment (PPE) supply for use as needed. The backyard was clean and orderly, and had patio furnishings, and shade cover for resident use.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NATASHA'S HOME
FACILITY NUMBER: 496803759
VISIT DATE: 08/13/2024
NARRATIVE
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LPA is requesting the following documents be updated and submitted by 9/13/24.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed and/or required)
Infection Control Plan (ensure to review and update as needed and/or required)
Copy of LIC400 Handling of Client Cash Resources (must complete, include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate.

The following deficiency was observed and will be cited, see LIC809D.

Hot water was checked at 134.9 degrees Fahrenheit which is not in compliance with regulation, hot water to be no higher than 120. degrees Fahrenheit and no lower than 105. degrees Fahrenheit. Administrator turned down the water heater during the inspection.

Deficiency citation, 87303(e)(2) Maintenance and Operation- Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C), see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator.
Appeal Rights provided to the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/13/2024 03:41 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/13/2024 at 02:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NATASHA'S HOME

FACILITY NUMBER: 496803759

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303(e)(2) Maintenance and Operation- Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the hot water being checked at 134.9 degrees Fahrenheit, which is not in compliance with regulation, the licensee did not comply with the section cited above which poses an immediate health, safety risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
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Licensee/Administrator to ensure the hot water is monitored and under 120.degrees Fahrenheit, and not to be under 105. degrees Fahrenheit. Monitor the hot water for a period of one week (7 days). Submit a copy of the hot water log, and a plan on how the facility will ensure the hot water is maintained in compliance with regulation. Submit plan of correction by 8/14//24, and follow up with copy of hot water log and maintenance plan by 8/21/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


LIC809 (FAS) - (06/04)
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