286804013-12-15-2023-21-AS-HRUS-CYJU9X-20231215142352

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804013
Report Date: 12/15/2023
Date Signed: 12/15/2023 02:23:56 PM

Document Has Been Signed on 12/15/2023 02:23 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	GRAMMA'S HOUSE		FACILITY NUMBER:	286804013
ADMINISTRATOR:	HAHKLOTUBBE, JULIET		FACILITY TYPE:	740
ADDRESS:	2529 VINE HILL CT.		TELEPHONE:	(707) 815-3368
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 6	DATE:	12/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator/ Licensee, Juliet Hahklotubbe		TIME COMPLETED:	02:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct an Annual Required inspection and was greeted by staff. LPA and staff discussed the purpose of the visit. Administrator/ Licensee, Juliet Hahklotubbe arrived shortly after. LPA initiated a tour of the facility around 12:00PM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 105, 123, and 118 degrees F which are not within the range of 105 to 120 degrees F allowed per regulation. Per conversation with Administrator, the hot water heater was recently replaced and is on the lowest setting. LPA and Administrator discussed submitting a temperature log to LPA for each resident sink until Monday 12/18/2023. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were 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. Emergency food and water supplies are stored in the garage along with Personal Protective Equipment. Fire extinguishers were last serviced February 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 12/01/2023. Four staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Administratior Certificate for Administrator, Juliet Hahklotubbe (6002637740), is up to date and expires 06/15/2025. Medications and medication records were reviewed. Contined on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: GRAMMA'S HOUSE	FACILITY NUMBER: 286804013
	VISIT DATE: 12/15/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Contined from LIC809

Administrator to submit updates of the following documents by 01/15/2024:
LIC 500 Personnel Summary
Copy of Liability Insurance
LIC 9020 Register of Residents
Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

No deficiencies cited during this inspection.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2