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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803969
Report Date: 05/25/2021
Date Signed: 05/25/2021 08:57:04 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ANNIE'S FAMILY HOME CARE OF CALISTOGAFACILITY NUMBER:
286803969
ADMINISTRATOR:VILLASENOR, SUSANNAFACILITY TYPE:
740
ADDRESS:1119 MITZI DR.TELEPHONE:
(707) 326-1994
CITY:CALISTOGASTATE: CAZIP CODE:
94515
CAPACITY:6CENSUS: 0DATE:
05/25/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Susanna VillasenorTIME COMPLETED:
09:15 AM
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Licensing Program Analyst (LPA) Angela Elliott conducted a pre-licensing inspection on 10/1/2020 via tele-visit. Due to COVID – 19 precautions, a facility visit is not able to be conducted at this time. LPA spoke with applicant Susanna Villasenor. The facility has a fire clearance from the City of Calistoga for a total of 5 non-ambulatory resident and 1 bedridden resident approved on 4/27/2020.

LPA observed all exits were unobstructed. Facility has three bedrooms and two bathrooms. Laundry area was open but toxins were located either in locked cabinets or secured areas. Water temperature measured between 110-112 degrees Fahrenheit in areas accessible to residents. LPA observed multiple carbon monoxide detectors and smoke detector alarms which were found to be operational. The fire extinguishers were inspected on 4/16/2021.

Medications will be locked in a cabinet off the entry way area. Knives were observed locked and inaccessible in a kitchen drawer. The facility has extra linens and hygiene supplies available. Bathroom had required non-slip mats and grab bars. Resident bedrooms contained required furnishings. Night lights were observed in the hallway. First Aid kit was present. Postings noted to be current and in compliance with regulations. noted.

The Component III Orientation was completed with applicant.

*signatures in file
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
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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