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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804013
Report Date: 10/14/2022
Date Signed: 10/14/2022 11:55:44 AM


Document Has Been Signed on 10/14/2022 11:55 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:GRAMMA'S HOUSEFACILITY NUMBER:
286804013
ADMINISTRATOR:HAHKLOTUBBE, JULIETFACILITY TYPE:
740
ADDRESS:2529 VINE HILL CT.TELEPHONE:
(707) 815-3368
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 6DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator/Licensee, Juliet HahklotubbeTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 10/14/2022 to conduct a Required - 1 Year Inspection and met with administrator/licensee, Juliet Hahklotubbe. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPA was screened for COVID symptoms and asked to sign in by staff. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with licensee and observed COVID postings throughout. Infection control plan has been submitted to Community Care Licensing (CCL). Facility was a comfortable temperature and exits were free from obstructions. Updated infection control guidelines and PINs are communicated to residents and responsible parties. Staff have completed Personal Protective Equipment (PPE) and infection control training through the county. High touch surface areas are disinfected daily. Residents' emergency contact information has been updated and licensee confirmed staff are familiar with 911 procedures and protocols. Medications are locked and inaccessible in a locked garage locker. Toxins are locked and inaccessible.

LPA requested the following documents be submitted within 30 days of today's inspection:

LIC 308 Designation of Facility Responsibility
LIC 9020 Facility Roster
LIC 610 Emergency Disaster Plan
Evidence of Liability Insurance
LIC 500 Personnel Report

No deficiencies observed during the inspection. Exit interview conducted with administrator and a copy of the emailed to the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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