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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803839
Report Date: 08/01/2024
Date Signed: 08/01/2024 04:19:58 PM

Document Has Been Signed on 08/01/2024 04:19 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:FAMILY HOUSEFACILITY NUMBER:
496803839
ADMINISTRATOR/
DIRECTOR:
GUZMAN ESTELITA, MARIA VFACILITY TYPE:
740
ADDRESS:6084 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7367
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 9CENSUS: 8DATE:
08/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Estelita Guzman-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 8/1/24 at approximately 2:30pm, and met with Licensee/Administrator Estelita Guzman. LPA observed the Administrator, and two (2) caregivers working at the time of arrival. There are currently eight (8) residents in care. There are nine (9) private resident rooms.

Fire clearance is approved for nine (9) non-ambulatory, of which two (2) may be bedridden.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Facility has a required infection control plan. The facility has an emergency disaster plan as required.

The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. All required postings were observed to be up on the walls as required.

LPAs toured the facility with the Administrator. All exits were free and clear of obstruction. All exits had auditory alarms. There was a sufficient food supply. There was a sufficient supply of linens, paper products, cleaners/disinfectants, hygiene supplies, and personal protective equipment (PPE). The facility was clean and orderly.

Facility had sufficient furnishings for resident use. Facility had sufficient lighting in resident rooms, bathrooms, hallways, and all common areas for residents in care. Bathrooms had grab bars, and mats in all showers for resident use. The backyard deck has patio furnishings and shade umbrellas for resident use. There is a front yard ramp and two backyard ramps for resident use, and to use in the event of an emergency.

The annual inspection will be continued at a later date.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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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