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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602733
Report Date: 07/08/2024
Date Signed: 07/08/2024 12:25:17 PM

Document Has Been Signed on 07/08/2024 12:25 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SANTA ROSA A.R.F.FACILITY NUMBER:
374602733
ADMINISTRATOR/
DIRECTOR:
JOHN DURKEEFACILITY TYPE:
735
ADDRESS:1234 DOLPHIN CIRCLETELEPHONE:
(760) 631-1511
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 6CENSUS: 6DATE:
07/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:John Durkee - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with John and Ann Durkee, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and zero (0) clients present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were in good repair and were present. The outdoor area was observed to be free of hazards and contained a shaded seated area for clients. The sharp and dangerous objects were observed to be locked and inaccessible to clients in care. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at met department requirements. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA reviewed two (2) staff files and training. All staff have personal records, criminal record clearance, health screening and current CPR/First Aide Certification. Three (3) client files were reviewed, and possessed all required paperwork including Admissions Agreement, Annual Physician's Report, and current Individual Program Plan (IPP). LPA inspected the P&I for three (3) clients and found no discrepancies. All client medication was centrally stored and locked in a cabinet located in the kitchen. LPA reviewed medications for six (6) clients and found all medication listed on the Medication Administration Record (MAR) and all required labeling and signatures were found to be in place. Facility has the emergency and disaster plan and infection control plan readily available for review. LPA observed emergency supplies and first aid kit with all required items. Facility staff conducts quarterly disaster drills that meets Department requirements. The facility does not contain any bodies of water on the property. There are no firearms or ammunition stored at the facility. No deficiencies were cited at the time of the visit.



An exit interview was conducted where a copy of this report was provided to Durkee.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2024
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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