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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804062
Report Date: 05/30/2024
Date Signed: 05/30/2024 12:46:39 PM


Document Has Been Signed on 05/30/2024 12:46 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: 6DATE:
05/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Maria HernandezTIME COMPLETED:
01:00 PM
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to review resident and staff files for the annual inspection which began on 05/29/2024. LPA met with Administrator Maria Hernandez. At approximately 11:15AM, LPA reviewed 5 of 6 resident records and found all records contained the required documents. Medication records are thorough and contained physician's orders for each resident.

At approximately 12:00PM, LPA reviewed 5 of 5 staff records and found all records contained evidence of required training. Evidence of current first aid and CPR training were current. LPA interviewed 3 staff and 2 residents during this inspection.

At approximately 12:30PM, LPA reviewed the facility emergency disaster plan. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts and documents disaster drills quarterly.

Updated copies of the following documents were received during visit:
LIC500- Personnel Report
LIC308-Designation of Facility Responsibility
Evidence of Liability Insurance

No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
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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