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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804062
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:51:18 PM


Document Has Been Signed on 08/26/2022 12:51 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:4K SENIOR HOME, LLCFACILITY NUMBER:
286804062
ADMINISTRATOR:HERNANDEZ, MARIA SOCORROFACILITY TYPE:
740
ADDRESS:4147 MAHER STREETTELEPHONE:
(707) 226-1293
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 5DATE:
08/26/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator/Licensee, Maria Socorro HernandezTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos conducted an unannounced POST licensing inspection of this licensed senior care facility. LPA was initially greeted by caregiver. Administrator was contacted and arrived a short time later. LPA toured the building and grounds which were found to be clean and in good repair. There are currently 5 resident in care. All walkways and exits were observed to be unobstructed.

The amount of fresh and nonperishable foods is within regulation. Toxins are stored in garage and are therefore inaccessible to residents in care. Medications are centrally stored in a locked cabinet. Fire extinguisher inspected was charged dated 02/03/2022. Carbon monoxide and smoke detectors were observed throughout the facility. There was an ample supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. All bedrooms have lighting & appropriate furnishings. Exit alarms on exit doors were working properly.

LPA reviewed 4 staff records. 4 out of 4 staff have current CPR and First Aid training.

At primary entrance LPA observed temperature log and visitor sign in sheet. LPA observed COVID postings and hand sanitizer throughout facility.

LPA requested current copy of Liability Insurance during visit.

Exit interview conducted with administrator/licensee Maria Socorro Hernandez. LPA was unable to print. Report was emailed to administrator/licensee.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
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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