<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803941
Report Date: 04/29/2021
Date Signed: 04/30/2021 09:42:57 AM

Document Has Been Signed on 04/30/2021 09:42 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ASHKALON HOUSEFACILITY NUMBER:
496803941
ADMINISTRATOR:DADA, VICTOR C.FACILITY TYPE:
740
ADDRESS:912 DETURK AVE.TELEPHONE:
(707) 478-7411
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 0DATE:
04/29/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Applicant, Victor DadaTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Willis met with Applicant, Victor Dada virtually to conduct a Pre-Licensing Inspection. Parties met remotely to observe Covid-19 precautions.

LPA and Applicant toured the inside of the facility and grounds via video conference. Facility is a one-story residence with six bedrooms, five bathrooms, a living room and a kitchen. All bedrooms are designated as single occupancy. Facility bedrooms have all personal accommodations. Residents bedrooms had the required furnishings, such as a dresser, night stand, lamp and bed linens. Bathrooms showers have a non-skid shower floor and grab bars for safety. Facility received an approved fire clearance dated March 29, 2021 that allows for six non-ambulatory residents. LPA observed required postings (LTCO, CCL Complaint poster, visitor policy, employee rights, personal rights and COVID-19 postings). Applicant showed what contents are in their First Aid Kit. Applicant tested the water temperature at 112 degrees F which is within regulation of 105 & 120 degrees F.

Facility will lock centrally stored medications in a cabinet in the kitchen. LPA observed that cleaning supplies and toxins are locked in a cabinet under the kitchen sink and in a locked cabinet in the laundry room. Perishable and non-perishable foods observed per regulation. Facility has space indoors and outdoors for resident activities.

LPA observed that facility has a gate that is coded and has the potential to be locked from the inside so questioned if the Applicant was interested in a locked perimeter to which Applicant responded that they were. LPA will discuss a waiver for a locked perimeter with the Application Unit.

Applicant stated that right now they are planning to use five bedrooms for residents and maintain the sixth room as a staff room.

Component III was completed with Applicant.

LPA will notify Application Unit so application process may proceed.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1