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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803941
Report Date: 05/19/2023
Date Signed: 05/19/2023 01:26:53 PM

Document Has Been Signed on 05/19/2023 01:26 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: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: 2DATE:
05/19/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator, Victor DadaTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct a Plan of Correction visit and was greeted by Administrator, Victor Dada.

LPA is following up regarding deficiencies cited during the May 8, 2023 Annual Required inspection.

The following deficiencies have been corrected:
87202(a)(2) - Licensee submitted the LIC200 and Facility Sketch
1569.618(c)(3) - Licensee has submitted copies of staff's First Aid and CPR Certificates.
87506(b)(15) - Admission Agreements for noted residents have been completed
87458(b)(1) - R1 no longer resides in the facility

The following deficiency is not due until 5/31/2023:
1569.625(b)(2) - Annual Training for all caregivers

A fire clearance was requested and denied to retain a resident who is bedridden. During inspection, LPA learned that the resident has moved from the facility to a higher level of care. Licensee was provided instruction from the fire department indicating what would need to be changed in order to have an approved bedridden fire clearance. LPA explained that facility may not admit or retain a resident who is bedridden until the fire department approves a bedridden fire clearance.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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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