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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803581
Report Date: 08/28/2024
Date Signed: 08/28/2024 12:41:38 PM


Document Has Been Signed on 08/28/2024 12:41 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:C&F SENIOR CARE HOME AMERICAN CANYONFACILITY NUMBER:
286803581
ADMINISTRATOR:FOJAS, LINAFACILITY TYPE:
740
ADDRESS:178 SONOMA CREEK WAYTELEPHONE:
(707) 246-0867
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY:5CENSUS: 4DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lina FojasTIME COMPLETED:
12:55 PM
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At approximately 10:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Lina Fojas and explained the purpose of the visit. Administrator certificate is current. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. First Aid/CPR certification was current. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required seven-day non-perishable and two day perishable supply of food. Medication is locked and not accessible. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. Facility has fire sprinklers throughout. All employees requiring background checks are cleared. Staff annual training was current. No pools/bodies of water are on the premises. Facility has been conducting drills every 3 months.

Exit interview conducted and copy of report was provided to administrator.

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


Current Lease Agreement
LIC500- Personnel Report
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: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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