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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804138
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:36:58 PM

Document Has Been Signed on 02/02/2023 03:36 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:TAKING THE JOURNEY NORTHFACILITY NUMBER:
496804138
ADMINISTRATOR:ERIKSEN, KELLYFACILITY TYPE:
740
ADDRESS:2125 MCSWEEN LNTELEPHONE:
(707) 338-8812
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 0DATE:
02/02/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Kelly Eriksen - AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Hansen conducted a pre-licensing inspection and met with Administrator Kelly Eriksen. Fire clearance has been approved for 5 non-ambulatory & 1 bedridden resident by the Rancho Adobe Fire District. LPA will conduct a component III orientation with Administrator Kelly Eriksen. Facility has a dementia care program and a request for hospice waiver for 2.

LPA toured facility and observed: Facility is a one floor residence in good repair and at a comfortable temperature. Hot water temperature checked 115.7 degrees F to 117.8 degrees F in 3 out of 3 resident's bathrooms as required by Title 22 Regulations and Fire Extinguisher was last checked on 12/07/2022. The facility has a phone line designated for resident’s use. There is an ample supply of personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Personnel and residents' records will be stored in locked front hallway closet. Locked cabinets in office will contain centrally stored medications. Facility plans on having awake staff. Grounds contain 3 locked sheds for storage and tools. Facility well water has been tested and is cleared for human consumption.

The facility has five resident’s bedrooms and three bathrooms. Facility has a kitchen, laundry room, living room area, office, dining room, and music room. Facility plans on having several different activities available for residents as desired. There is outdoor deck space for activities and visiting. Resident's & Personnel records, medication, first aid supplies, and toxins will be locked. Postings noted to be current and in compliance with guidelines. Locked cabinets for sharps in kitchen and cleaning/laundry supplies in locked cabinet in laundry room. First aid kit was observed. Emergency supplies and PPE located in the front entry closet. All exits have egress alarms. Infection Control Plan has been submitted.


Facility is cleared for licensure.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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