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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804159
Report Date: 07/20/2023
Date Signed: 07/20/2023 10:23:24 AM

Document Has Been Signed on 07/20/2023 10:23 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:GRACIOUS LIVING AT PORTER CREEK LLCFACILITY NUMBER:
496804159
ADMINISTRATOR:MUNGAI, PHOEBEFACILITY TYPE:
740
ADDRESS:3069 PORTER CREEK RDTELEPHONE:
(707) 569-8137
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 5DATE:
07/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:TIME COMPLETED:
10:33 AM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived announced to conduct a Pre-Licensing Inspection and met with Applicant, Phoebe Mungai. Applicant has applied for a Change of Ownership of an existing Residential Care for the Elderly Facility.

Facility is a one story residence with four bedrooms (two shared, two private), three and a half bathrooms, an office and common areas. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Bathroom showers have non-skid shower floor and grab bars. Water temperature read at 114 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Facility has a locked closet in the kitchen used for centrally stored medications. Cleaning supplies and toxins are locked in a cabinet under the kitchen sink and in a cabinet in the laundry room. Perishable and non-perishable foods are stored per regulation. Facility has areas inside and outside for visiting and activities.

Facility received an approved fire clearance dated May 23, 2023 that allows for up to four non-ambulatory and two bedridden residents. Facility has combination Smoke/Carbon Monoxide detectors that were tested during the fire inspection. Facility has a generator in case of a power outage. Facility is currently locking a gate off the patio. LPA will obtain clarification from the fire department whether the gate may be locked as it may be considered an exit.

LPA gave Applicant information on how to sign up for the Guardian and Provider Information Notices (PINs). Component III was conducted with Applicant. LPA notified Applicant that once licensed, they will need to complete new Admission Agreements and Care Plans for all residents,

Once clarification is received by the fire department, LPA will notify Application Unit so application process may proceed.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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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