496804270-2-19-2025-21-AS-DALO-DE2RHY-20250219120308

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804270
Report Date: 02/19/2025
Date Signed: 02/19/2025 12:03:16 PM

Document Has Been Signed on 02/19/2025 12:03 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:	AILA CARE HOME		FACILITY NUMBER:	496804270
ADMINISTRATOR/ DIRECTOR:	MONTE, AIRA MELANIE U		FACILITY TYPE:	740
ADDRESS:	4766 FAIRWAY DR		TELEPHONE:	(628) 259-2954
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY: 6		CENSUS: 0	DATE:	02/19/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Laarnie Lockerbie-Applicant		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Alviso and Contreras conducted a pre-licensing inspection, at approximately 9:00am on 2/19/25, and met with Applicant Laarnie Lockerbie. Component III orientation was held with Applicant Laarnie Lockerbie, Aira Monte, and Armabela Monte, on 2/19/25. Aira and Armela Monte both have active RCFE administrator certificates; Aira Monte is a Nurse and has a primary job at a hospital. Applicant Laarnie Lockerbie will be submitting an updated personnel report, LIC500, on 24/7 proposed staffing schedule, and who the primary Administrator will be, and Administrator work schedule (days/hours) as discussed. If Nurse, Aira Monte is the primary Administrator, please submit their hospital work schedule, including days/hours working. Please note as discussed, the Administrator must be on-site business days and hours to ensure the facility's plan of operation. Any questions, please contact me. If Armebela Monte is the Primary Administrator, please submit their Administrator certificate, and show days/hours working on the LIC500 personnel report. Please submit an LIC308 Designation of Facility Responsibility form for Armebela Monte, if the hired Administrator. Applicant has submitted a dementia plan of operation. The applicant has requested a hospice waiver for two (2) residents. Applicant has submitted a required emergency disaster plan, and a required infection control plan. Applicant has an approved fire clearance for six (6) non-ambulatory residents- effective 1/17/25. There is a carbon monoxide detector in the facility that was working properly during the inspection. All required rooms have a smoke alarm as required by the local Fire Department. Fire extinguisher was serviced and tagged as required. All exits were free and clear from obstruction. All exits had auditory alarms. There are five (5) resident rooms, and one of them is a shared room. Continued on LIC809C....

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AILA CARE HOME	FACILITY NUMBER: 496804270
	VISIT DATE: 02/19/2025

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The LPA toured the facility with applicant. Bathrooms had non-slip mats for resident use as needed. Hot water was checked at 109.9 degrees Fahrenheit. All resident rooms were clean, orderly, and had all required accommodations. Facility had sufficient lighting in resident rooms, bathrooms, and common areas. Medications will be stored in locked cabinets. All disinfectants/cleaners were locked up as required. The facility was clean and orderly during the inspection. Facility had a supply of non-perishable food. Facility had a supply of emergency drinking water. Sufficient supply of linens, dishes, and furnishings for resident use. The backyard and deck were observed to be clean and orderly. The fire exit ramps, one off the backyard deck, and the other in the front of the home were observed to be clean and free of obstruction. All outside walkways/pathways were free and clear of obstruction as required. The backyard had an in-ground pool that has been filled with dirt, this is not a health & safety hazard as is today, 2/19/25.

The following items need to be corrected/completed:

Applicant to ensure there is a grab bar handle by the bathroom toilets in each resident restroom for resident's use.
An emergency supply of food and water in order to meet the "72 hour shelter in place" requirement.
A latch on the inside of the backyard fire exit gate in order to open the gate from the inside as required/needed in the event of an emergency.
Personnel report LIC500, including the discussed Administrator days/hours, and who will be the primary Administrator. Including LIC308 if needed.
A medication lock box for the refrigerator to use as needed/required.

Send photos/documents/receipts to clear corrections. Once the above is received the LPA will review for completion/approval.

LPA will notify the application unit Analyst once all corrections are completed. LPA will submit a copy of the report to the application unit with LPA recommendation of application/pre-licensing inspection. The application Analyst will notify the applicant of the application's status.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC809 (FAS) - (06/04)

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