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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126804144
Report Date: 06/05/2023
Date Signed: 06/05/2023 01:16:49 PM


Document Has Been Signed on 06/05/2023 01:16 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:REDWOOD R AND RFACILITY NUMBER:
126804144
ADMINISTRATOR:CRAVEN, HEATHERFACILITY TYPE:
740
ADDRESS:3231 DOLBEER STTELEPHONE:
(805) 975-5427
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:14CENSUS: 8DATE:
06/05/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Heather CravenTIME COMPLETED:
01:30 PM
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At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility for the purpose of completing a pre-licensing evaluation. LPA met with Applicant Heather Craven and toured the facility. The Facility is a 7-bedroom, 4-bathroom, single story house. A Fire extinguisher was mounted and charged. Smoke detectors were tested and in working order. There was a locked area for medications and several for toxins and cleaning supplies. Beds were made with appropriate linens. Resident rooms contained the required furniture in 7 of 7 rooms. Hot water temperature was tested and found to be within regulation between 105 degrees F and 120 degrees F at faucets accessible to residents. Exit doors had working alert devices installed.

This facility has submitted a request for a hospice waiver and a plan to care for residents with dementia. The plan has been reviewed and all physical plant safeguards have been checked. The applicant's states that they do not plan to advertise at this time. A fire clearance for this facility has been granted.

Component III orientation was conducted at facility. Applicant conveyed a good knowledge of Title 22 regulations.

Applicant provided evidence of Liability insurance at the time of visit.

The pre-licensing evaluation has been completed. LPA will submit the application packet for a final review and approval from the Licensing Program Manager.

This report was reviewed with applicant and a copy was provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
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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