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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803969
Report Date: 06/13/2023
Date Signed: 06/13/2023 09:31:41 AM


Document Has Been Signed on 06/13/2023 09:31 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ANNIE'S FAMILY HOME CARE OF CALISTOGAFACILITY NUMBER:
286803969
ADMINISTRATOR:CARISMA PATTERSONFACILITY TYPE:
740
ADDRESS:1119 MITZI DR.TELEPHONE:
(707) 326-1994
CITY:CALISTOGASTATE: CAZIP CODE:
94515
CAPACITY:6CENSUS: 2DATE:
06/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Carisma PattersonTIME COMPLETED:
09:45 AM
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Administrator Carisma Patterson. At approximately 8:15AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage cupboard. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.
At approximately 8:45AM, LPA reviewed 2 of 2 resident records. 1 of 2 records did not contain a pre-appraisal. Administrator will ensure pre-appraisals are completed for future residents. 2 of 2 records contained current and signed admission agreements and physician's orders. Medication records are thorough and contained physician's orders for each resident.
At approximately 9:00AM, LPA reviewed 3 of 3 staff records. All training was current and evidence of current first aid and CPR was present.
Facility has a generator to supply power during an outage. Facility has supplies enough to operate for more than 72 hours in an emergency.

No citations issued during this visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023
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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