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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803358
Report Date: 01/24/2025
Date Signed: 01/24/2025 01:32:06 PM

Document Has Been Signed on 01/24/2025 01:32 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:HOLY SPIRIT RESIDENTIAL CARE HOME INC. IIFACILITY NUMBER:
236803358
ADMINISTRATOR/
DIRECTOR:
GONZALEZ, PERLAFACILITY TYPE:
740
ADDRESS:1275 ELM STREETTELEPHONE:
(707) 972-5831
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Perla GonzalezTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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At approximately 11:30AM, 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 11:40AM, 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 stored in a locked storage closet. 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 detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.
At approximately 12:00PM, LPA reviewed 5 of 5 resident records. All records contained current appraisals and completed physician reports. Admission agreements were signed and present in the records.

LPA will return at a later date to review staff records.

No citations issued during today's visit.
Bethany MoellersTELEPHONE: (707) 588-5040
Christopher ArnholdTELEPHONE: (707) 588-5084
DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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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