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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804078
Report Date: 07/02/2024
Date Signed: 07/02/2024 11:53:44 AM

Document Has Been Signed on 07/02/2024 11:53 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MARIA ZOILA INCFACILITY NUMBER:
236804078
ADMINISTRATOR/
DIRECTOR:		BARLAHAN, ROSS EVAN P.FACILITY TYPE:
735
ADDRESS:48A WHITMORE LANETELEPHONE:
(707) 635-9338
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 4CENSUS: 4DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Ross Barlahan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:07 PM
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Licensing Program Analyst (LPA) Jacky Macias arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Ross Barlahan.

At approximately 845am, LPA and Administrator toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner. Kitchen cabinet below the sink containing cleaning supplies was locked. Kitchen drawer with sharp knives was locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat. Water temperature in sink accessible to residents in care measured at 114.6 and 113.9 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected August 24, 2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted May 31, 2024. Facility has a backup generator for use during a power outage.

At approximately 9:00am, LPA conducted review of 5 staff records. All required documentation present.

At approximately 9:30am, LPA conducted a review of 4 of 4 client records all of which required documentation was present. Administrator has been attempting to get an updated Appraisal Needs and Services Plan for Client (C1) and an Appraisal Needs and Services Plan for Client (C2). (Technical Advisory cited).

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SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jacqueline Macias
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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: MARIA ZOILA INC
FACILITY NUMBER: 236804078
VISIT DATE: 07/02/2024
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At approximately 10:00am, Client cash resources were reviewed and verified.

At approximately 10:30am, LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies.

Ross Barlahan, Administrator Certificate 7025444735 expires 5/19/2025 . All fees are current as of this time.



Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610D- Disaster Plan
LIC400- Affidavit Regarding Client Cash Resources
LIC 402- Surety Bond


No deficiencies were observed in the areas inspected. No citations issued during today’s visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jacqueline Macias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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