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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803943
Report Date: 01/18/2024
Date Signed: 01/18/2024 12:00:30 PM

Document Has Been Signed on 01/18/2024 12:00 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:ALAMEDA HOMEFACILITY NUMBER:
216803943
ADMINISTRATOR:LIU, FANGFACILITY TYPE:
735
ADDRESS:405 ALAMEDA DE LA LOMATELEPHONE:
(415) 516-3162
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 4CENSUS: 3DATE:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Annie LiuTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:45AM to conduct an Annual Required inspection and was greeted by staff. LPA and staff discussed the purpose of the visit. Administrator, Annie Liu arrived shortly after.

LPA initiated a tour of the facility around 10:00 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 108 and 109 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food is stored in hall closet and emergency water is stored in the office along with Personal Protective Equipment. LPA observed a new shed in the backyard. Per conversation with Administrator, the shed will be used for storage. LPA is requesting a facility sketch that reflects the new shed in the backyard.

Fire extinguishers were last serviced May 2023. Facility has combination smoke/ carbon monoxide detectors located throughout the facility that were tested and operational during inspection. Most recent fire/disaster drill was conducted 12/19/2023. Medications and medication records were reviewed. Client cash resources were reviewed. Five staff files and three resident files were reviewed. Staff have required First Aid and CPR certificates. Administrative Certificate for Administrator, Annie Liu (7007002735) is up to date and expires 12/10/2024.




Continued on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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: ALAMEDA HOME
FACILITY NUMBER: 216803943
VISIT DATE: 01/18/2024
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Continued from LIC809

No deficiencies cited during inspection.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on forms confirms receipt of documents.

LPA is requesting the following to be submitted to Community Care Licensing by 02/18/2024:
LIC 500- Personnel Report
LIC 9020 Client Roster
LIC 308 Designation of facility responsibility
Surety Bond
Updated facility sketch
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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