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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803255
Report Date: 03/29/2024
Date Signed: 03/29/2024 11:58:52 AM


Document Has Been Signed on 03/29/2024 11:58 AM - 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:HOLY SPIRIT RESIDENTIAL CARE HOME, INC.FACILITY NUMBER:
236803255
ADMINISTRATOR:GONZALEZ, GENAROFACILITY TYPE:
740
ADDRESS:224 LAWS AVENUETELEPHONE:
(707) 462-0428
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:6CENSUS: 5DATE:
03/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Perla GonzalezTIME COMPLETED:
12:15 PM
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Administrator Perla Gonzalez. At approximately 8:45AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are inaccessible to residents. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Carbon Monoxide detector was present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.
At approximately 9:30AM, LPA reviewed 5 of 5 resident records and found 5 of 5 residents had current physician's reports, care plans, signed admission agreements and physician's orders for medications.
At approximately 11:00AM, LPA reviewed 4 of 4 staff records. All records contained documentation of completed training as required. Evidence of current first aid and CPR training were current.
At approximately 11:30AM, LPA reviewed the facility emergency disaster plan. Facility has a generator to supply power during an outage. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts disaster drills quarterly.
No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
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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