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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803849
Report Date: 07/11/2023
Date Signed: 07/11/2023 10:45:14 AM

Document Has Been Signed on 07/11/2023 10:45 AM - 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:ADOM MANOR CARE HOMEFACILITY NUMBER:
496803849
ADMINISTRATOR:KARIKARI, EVAFACILITY TYPE:
740
ADDRESS:2543 TACHEVAH DRTELEPHONE:
(707) 526-6895
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 5DATE:
07/11/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Eva KarikariTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Adom Manor Care Home for the purpose of conducting a Annual Continuation. LPA was greeted by Caregiver, Joel Karikari and was granted access into the facility. Licensee arrived 30 minutes later.

During this Annual Continuation, LPA reviewed the Emergency Disaster Plan with the Licensee. Emergency Generator was observed in the garage and ready for use. Quarterly Disaster Drill document was reviewed and the facility conducted the Quarterly Disaster Drill on June 29, 2023 with all staff on duty. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA interviewed staff and residents in care during the Annual Continuation. However, during staff interviews, LPA interviewed a staff member that needs more training on how to read Needs and Appraisal Plans. LPA educated the Licensee regarding ensuring that staff are trained to read the Needs and Appraisal Plans for ALL residents in care (See LIC 9102-Technical Assistance).

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308-Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Liability insurance
Control of Property
Register of clients

No deficiencies were observed or cited during today's Annual Continuation. Exit interview was conducted and a copy of this report was given to the facility Licensee.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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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