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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126804083
Report Date: 07/20/2022
Date Signed: 07/20/2022 03:32:40 PM


Document Has Been Signed on 07/20/2022 03:32 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:CARING COMPANIONS CARE HOMEFACILITY NUMBER:
126804083
ADMINISTRATOR:RASMUSSEN, COLLENFACILITY TYPE:
740
ADDRESS:2641 HALL AVETELEPHONE:
(707) 616-5693
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:15CENSUS: 8DATE:
07/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Collen RasmussenTIME COMPLETED:
03:45 PM
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold met with Applicant Collen Rasmussen, to conduct an unannounced pre-licensing inspection. LPA toured the facility bedrooms, common rooms and grounds. Facility has a total of nine bedrooms for residents. All doorways and walkways are unobstructed and facility is clean, in good repair and at a comfortable temperature. Hot water measured within acceptable range between 105 and 120 degrees F. at faucets accessible to residents. There are games and space for resident activities. There is an outdoor space with shade for residents and the yard is fully enclosed. Facility has a drawer in the kitchen to lock knives and other items dangerous to residents with dementia diagnosis. There are also locked closets containing toxins and cleaning supplies. LPA observed a good supply of back up linens and toiletries, and the kitchen is stocked with an ample supply of fresh and non-perishable foods per regulation.

Facility has pull station alarms and sprinkler system. Fully charged fire extinguishers, operable smoke alarms and carbon monoxide detectors were also in place. There was plenty of dishware and utensils. All appliances were in place and working. All required postings were posted at the entrance and throughout the facility.
Medications are centrally stored in a locking cabinet. Medications were found separated by resident and well organized. There is a secure storage area for resident records.

Applicant will provide evidence of Liability insurance to the central application unit analyst when received from insurance agent.
LPA conducted a Component III Orientation with applicant, and the applicant has shown that they have a good understanding of Title 22, and have appropriate knowledge to operate a residential facility.

LPA found this facility ready to be licensed. LPA will submit application to Licensing Program Manager for review.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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