<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176801307
Report Date: 08/08/2024
Date Signed: 08/08/2024 01:34:32 PM

Document Has Been Signed on 08/08/2024 01:34 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:MANZANITA HOUSEFACILITY NUMBER:
176801307
ADMINISTRATOR/
DIRECTOR:		MARIAH UDENFACILITY TYPE:
735
ADDRESS:3997 MANZANITA DRIVETELEPHONE:
(707) 274-9293
CITY:NICESTATE: CAZIP CODE:
95464
CAPACITY: 6CENSUS: 5DATE:
08/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Mariah Uden, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 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 Analyst (LPA) Hansen was at facility delivering findings of a complaint investigation and conducted case management due to additional issues found during investigation. LPA met with Mariah Uden, Administrator.

During complaint 21-AS-20240725130851 investigation, an allegation the facility was not within temperature regulation was investigated and although the facility was in regulation temperature LPA observed a swamp cooler placed in the living room glass door and an air conditioner in front of the back hallway exit door attached to door window (see pics).

Although LPA observed temperature within the regulations swamp and other air conditioning system is obstructing exit doors.

The Department has cross reported to the Fire Department and Building Commissioner/Code Enforcement

Facility given an Immediate $500. civil penalty for obstruction of exits.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/08/2024 01:34 PM - It Cannot Be Edited


Created By: Shannan Hansen On 08/08/2024 at 07:31 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MANZANITA HOUSE
FACILITY NUMBER: 176801307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2024
Section Cited
CCR
80020(a)

1
2
3
4
5
6
7
80020(a) Fire Clearance- All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement has not been met as evidenced by:
1
2
3
4
5
6
7
Administrator agrees to submit plan, so facility remains within temperature range of regulations without obstructing exits with portable air conditioner and swamp cooler. By POC due date of 8/9/2024
8
9
10
11
12
13
14
LPA observations during complaint investigation/ inspection. it was observed that there were two fire exit doors obstructed: the front sliding glass door with swamp cooler in front of the door & back of facility, fire exit door with air conditioner in front of the door (see pics), which is a fire code violation. This is a fire code violation. **Immediate Civil Penalty
8
9
10
11
12
13
14
***Immediate Civil Penalties are being assessed in the amount of $500 due to zero tolerance citation issued.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2