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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 121305711
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:02:58 PM


Document Has Been Signed on 05/04/2023 12:02 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:CUTTEN CARE HOMEFACILITY NUMBER:
121305711
ADMINISTRATOR:LENDE, SUZANNEFACILITY TYPE:
740
ADDRESS:6253 BERRY LANETELEPHONE:
(707) 444-3428
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:15CENSUS: 2DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Suzanne LendeTIME COMPLETED:
12:15 PM
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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Suzanne Lende. At approximately 9:00AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA 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. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.

At approximately 10:00AM, LPA reviewed 2 of 2 resident records and found 2 of 2 records contained current and signed admission agreements and physician's orders on file. Medication records are thorough and contained physician's orders for each resident.

At approximately 10:30AM, LPA reviewed 2 of 2 staff records. Records did not contain documentation of completed training records as required. At approximately 11:00AM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts and documents disaster drills quarterly with the last drill conducted 03/21/2023. Continued on LIC809-C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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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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: CUTTEN CARE HOME
FACILITY NUMBER: 121305711
VISIT DATE: 05/04/2023
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC610E- Disaster Plan


LPA received evidence of liability insurance during today's visit.

No citations were issued during today’s visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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