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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804138
Report Date: 02/06/2025
Date Signed: 02/06/2025 03:16:29 PM

Document Has Been Signed on 02/06/2025 03:16 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/
DIRECTOR:		ERIKSEN, KELLYFACILITY TYPE:
740
ADDRESS:2125 MCSWEEN LNTELEPHONE:
(707) 338-8812
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 6DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Kelly Eriksen, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Administrator Kelly Eriksen arrived later. Facility has 6 residents with 4 having dementia diagnosis. Facility has fire clearance for 6 Non Ambulatory with 1 bedridden. Facility currently has two residents on hospice and facility has a Hospice Waiver for six.

At approximately 8:15 am LPA and staff toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. LPA observed locked kitchen cabinet containing cleaning supplies and sharp knives.



All bedrooms were equipped with lighting/lamp, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required slip resistant mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 114.9 to 118 degrees F, within the allowable range of 105 to 120 degrees F.

Fire extinguishers were observed to be charged. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have an auditory alert system that was functional at time of inspection. Facility’s last quarterly disaster drill was conducted on 11/14/2024. Facility has a backup generator for use during a power outage.

At approximately 8:45 am on 2/5/2025 LPA conducted a review of five resident files and learned that 5 of 6 residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A).

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SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 NORTH
FACILITY NUMBER: 496804138
VISIT DATE: 02/06/2025
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At approximately 9:25 am on 2/5/2025 LPA conducted a review of six out of ten staff files and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements are current and LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed.

At approximately 10:00pm LPA and Admin conducted a spot check of medication and medication records. No discrepancies observed. Medication is centrally stored in a locked closet in the hallway.

Kelly Eriksen Administrator Certificate 7008387740 expires 11/5/2025. All fees are current. LPA and Admin discussed facility's Infection Control Plan and Emergency Disaster plan.

Exit interview conducted & copy of report left

No deficiencies cited during today's inspection

LPA Hansen has requested the following documents updated and submitted to CCL by 2/21/2025.
LIC500- Personnel Report
LIC308- Designation of Responsibility (if changes)
LIC9020 Register of Facility Residents
Administrator Certificate
Emergency Disaster Plan (if changed)
Copy of Current Liability Insurance
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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