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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236801874
Report Date: 08/19/2022
Date Signed: 08/19/2022 01:55:49 PM

Document Has Been Signed on 08/19/2022 01:55 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:THREE OAKS, INCFACILITY NUMBER:
236801874
ADMINISTRATOR:CABIE, BENJAMINFACILITY TYPE:
735
ADDRESS:181 NORTH COURT ROADTELEPHONE:
(707) 462-1902
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 6CENSUS: 5DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Ross Evan BarlahanTIME COMPLETED:
02:15 PM
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At approximately 12:45PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an Annual Required infection control inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPA was screened upon entry and temperature was taken. LPA met with house manager Ross Evan Barlahan.

Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged and inspected within the last 12 months.

Facility Posters are in place at the entrance and throughout the building. The entrance area has a small table with hand sanitizer, thermometer and other items designated for visitors and staff before coming into work or visit. Facility has PPE supplies. Facility has a 30-day supply of medication. Residents do not wear masks inside the facility but have them available. Staff were wearing masks during this visit.

Facility has submitted an Infection Control Plan.


There were no deficiencies found in the areas inspected.
No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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