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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804159
Report Date: 10/20/2023
Date Signed: 10/20/2023 11:58:54 AM

Document Has Been Signed on 10/20/2023 11:58 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: 4DATE:
10/20/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee Phoebe MungaiTIME COMPLETED:
12:10 PM
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At approximately 9:00AM, Licensing Program Analysts (LPAs) Victoria Bertozzi and Christi Coppo made an unannounced Post Licensing inspection visit. LPAs met with Licensee Phoebe Mungai. At approximately 9:30AM, LPAs toured the building and grounds which was found to be clean and in good repair. LPAs observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area.

The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerator, and freezer were clean, and food was stored properly. Toxins are stored in locked laundry room and locked under kitchen sink. Water temperature at faucets accessible to residents measured at 117.3F and 104.7F, respectively, which is within regulation.

Fire extinguishers inspected 11/08/2022 were charged. Smoke detectors/Carbon Monoxide detectors were tested and functional. There was enough lighting in all common areas, resident rooms, and hallways. NIghtlights present in hallways. Medication is centrally stored in the locked kitchen pantry.

At approximately 9:30AM LPAs observed facility to have enough supplies to operate for more than 72 hours in an emergency.

At approximately 10:45AM, LPAs reviewed 4 resident records and found residents to have physician's reports, signed admission agreements, care plans and physician's orders on file. LPAs reviewed 4 of 7 staff records. CPR and first aid certificates were current.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610E- Disaster Plan (if any changes)


No deficiencies were observed in the areas inspected, No citations were issued during today’s visit
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
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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