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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801593
Report Date: 07/24/2024
Date Signed: 07/24/2024 12:06:20 PM


Document Has Been Signed on 07/24/2024 12:06 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SAINT HELENA HOME CAREFACILITY NUMBER:
286801593
ADMINISTRATOR:GUTIERREZ, MARIA JUANAFACILITY TYPE:
740
ADDRESS:2011 OLIVE ST.TELEPHONE:
(707) 967-9549
CITY:ST. HELENASTATE: CAZIP CODE:
94574
CAPACITY:6CENSUS: 5DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Maria J Gutierrez, AdministratorTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) J. Macias arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Maria J. Gutierrez. Facility contact information was reviewed.

At approximately 09:30am 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 with open items covered and dated. Kitchen drawer with sharp knife was locked. Cleaning supplies were locked and inaccessible to residents in care. All bedrooms were equipped with lighting, night stand, and chest of drawers per regulation. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Water temperature in sink accessible to residents in care measured at 110.3 and 110.1 degrees F, which is within the allowable range of 105 to 120 degrees F per regulation.

Fire extinguishers were last inspected February 22, 2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted April 27, 2024. Administrator to conduct next quarterly drill before July 27, 2024.

At approximately 10:30am LPA conducted a review of five (5) resident records. All required documentation present.

At approximately 11:30am LPA conducted review of four (4) staff records. All required documentation present.

At approximately 12:00pm LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored in a locked closet. No deficiencies.

Continued on 809C...

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jacqueline MaciasTELEPHONE: (707) 588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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: SAINT HELENA HOME CARE
FACILITY NUMBER: 286801593
VISIT DATE: 07/24/2024
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Administrator Certificate for Administrator, Maria Juana Gutierrez 6021257740 expires 10/6/2024.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: 8/24/2024

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jacqueline MaciasTELEPHONE: (707) 588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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