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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801593
Report Date: 06/23/2023
Date Signed: 06/23/2023 11:21:49 AM


Document Has Been Signed on 06/23/2023 11:21 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: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: 4DATE:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Maria Juana GutierrezTIME COMPLETED:
11:31 AM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Licensee/Administrator, Maria Juana Gutierrez.

LPA initiated a tour of the facility around 9:20 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 103 and 104 degrees F which are not within the range of 105 to 120 degrees F allowed per regulation. LPA observed that staff was doing laundry which may explain why water temperature was low. LPA asked Licensee to continue to measure water throughout the day to ensure it reaches a temperature that is within the range allowed per regulation. Extra hygiene products and linens were available. Cabinet in garage containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility maintains emergency food and water supplies.

Fire extinguishers were fully charged and last serviced May 2022. LPA reminded Licensee that fire extinguishers are to be serviced yearly. Licensee will have fire extinguishers serviced as soon as possible. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent disaster drill was conducted 4/2023.

Three staff files and four resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Maria Juana Gutierrez 6021257740 expires 10/6/2024. Medications and medication records were reviewed.

Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
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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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: 06/23/2023
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Continued from LIC809

Licensee/Administrator to submit updates of the following documents by 7/23/2023:


LIC 500 Personnel Summary
LIC308 Designation of Facility Responsibility
Copy of Liability Insurance
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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