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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803764
Report Date: 06/09/2022
Date Signed: 06/09/2022 02:20:07 PM

Document Has Been Signed on 06/09/2022 02:20 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:OUR HOUSEFACILITY NUMBER:
126803764
ADMINISTRATOR:SHANNON, ALEXANDERFACILITY TYPE:
735
ADDRESS:3309 MONTGOMERYTELEPHONE:
(707) 268-0679
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY: 4CENSUS: 4DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Sara MeltonTIME COMPLETED:
02:35 PM
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At approximately 1:15 PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an Annual Required infection control inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPA met with Licensee Sara Melton.

LPA arrived at the facility and had temperature checked and health questions asked. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged and inspected within the last 12 months. Facility Posters are in place at the entrance and throughout the building. The entrance area has hand sanitizer, thermometer and other items designated for visitors and staff before coming into work or visit. Facility has PPE supplies. Facility has a 30-day supply of medication. Residents do not wear masks inside the facility but have them available.

There were no deficiencies found in the areas inspected.

No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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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