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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803577
Report Date: 10/29/2024
Date Signed: 10/29/2024 01:30:11 PM

Document Has Been Signed on 10/29/2024 01:30 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WALDO HOUSEFACILITY NUMBER:
216803577
ADMINISTRATOR/
DIRECTOR:		LOTT, SHERIFACILITY TYPE:
735
ADDRESS:55 WALDO COURTTELEPHONE:
(415) 271-3304
CITY:SAUSALITOSTATE: CAZIP CODE:
94965
CAPACITY: 5CENSUS: 4DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Sheri Lott, Administrator
Twon Blake, staff
Tanya Barreto, staff		TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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10/29/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. LPA was greeted by staff member, Twon Blake. Tanya Barreto, arrived shortly after LPA arrived. Administrator, Sheri Lott arrived later during visit. There are currently 4 clients in care. Facility approved/cleared for 1 non-ambulatory. There was 3 clients present during visit.

At approximately 10:20am, LPA and staff toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. LPA noticed the bottom of a corner wall in the bathroom had a small area that was broken/decayed wood. Staff notified LPA he is fixing up around the house and showed previous before and after photos of replacing the kitchen and bathroom floor. As well as a list of what needs to be done around the house, he has planned with the broken/decayed wood being on the list to replace. Water temperature in sinks accessible to clients in care were measured at 118.2 and 117.5 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected August, 2024. Toxins, sharps and other items that could pose threat if available to clients were located in a locked cabinet in the kitchen. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Facility conducts fire/evacuation drills monthly with the last one being done 09/18/2024.

LPA conducted a review of four client records. All records had the required documentation. Cash resources were documented.

continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WALDO HOUSE
FACILITY NUMBER: 216803577
VISIT DATE: 10/29/2024
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LPA conducted review of four staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

LPA followed up on an incident report that was reported to CCL on 10/17/2024. Incident report states client 1 had a behavioral episode that resulted in injury while on the way home from the grocery store. Client 1 quickly unbuckled his seat belt and ran around the back seat of the van, opened the back door and exited the van prior to the driver being able to bring the van to a complete and safe stop. LPA checked on current status of client and found out the client is currently out of ICU and was transferred to medical unit. Client Is no longer on sedation. Client opens eyes and is responsive. Staff told LPA CHP responded to the accident, EMS and the fire department responded first.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610- Emergency Disaster plan (if any changes)
Infection Control Plan (if any changes)

Exit interview conducted with Administrator and a copy of this report was provided.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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