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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803766
Report Date: 11/30/2023
Date Signed: 11/30/2023 01:16:27 PM


Document Has Been Signed on 11/30/2023 01:16 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:AZALEA HOUSEFACILITY NUMBER:
236803766
ADMINISTRATOR:JESSICA GRINBERGFACILITY TYPE:
740
ADDRESS:209 AZALEA CIRTELEPHONE:
(707) 964-4940
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY:4CENSUS: 3DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jessica GrinbergTIME COMPLETED:
01:30 PM
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At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Jessica Grinberg. At approximately 11:00AM, 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 highly visible areas. 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. Facility has fire sprinklers throughout. 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 11:30AM, LPA reviewed 3 resident records which were thorough and contained the required documents. Medication records are thorough and contained physician's orders for each resident. At approximately 12:15PM, LPA reviewed 5 staff records. 5 of 5 records contained evidence of completed training as required. Evidence of current first aid and CPR training were current. LPA interviewed 2 staff during this inspection. At approximately 12:50PM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 11/04/2023.
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: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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