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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202974
Report Date: 08/18/2022
Date Signed: 08/18/2022 12:25:02 PM

Document Has Been Signed on 08/18/2022 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HANA HOU ALLIANCEFACILITY NUMBER:
397202974
ADMINISTRATOR:MARRIOTT, ANNEFACILITY TYPE:
735
ADDRESS:12005 E. LOCKE ROADTELEPHONE:
(209) 727-3991
CITY:LOCKEFORDSTATE: CAZIP CODE:
95237
CAPACITY: 6CENSUS: 6DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kim ContrevoTIME COMPLETED:
12:30 PM
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On 8/18/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Kim Contrevo and explained the purpose of today's visit.

The facility is a single story building with a sole designated entrance set up with a sign in sheet, sanitizer and temperature check for COVID screening. The front door has informational COVID signs posted as required. There is a swimming pool on the grounds that is surrounded by a gate and the entrance to the pool area was observed to be locked. The grounds and pool area were observed to be well maintained and clear of debris.

LPA Jensen toured the facility including but not limited to 2 bathrooms, 2 bedrooms, 2 kitchens, a dining room and living room. The thermostat was set at 74 degrees and falls within the regulatory range of 68-85 degrees for the comfort of the residents. The fire extinguisher was last serviced on 7/30/22 and is in compliance. The carbon monoxide detector was tested and is in good working order. A first aid kit was observed to be complete with tweezers, scissors, thermometer, manual and various wound dressings. The facility was observed to be clean, equipped with adequate lighting and free of odor. The facility keeps emergency supplies on hand including emergency lighting, credit cards, emergency food and water. The emergency disaster plan( LIC 610D) was reviewed and in compliance.

The kitchen was observed to maintain in excess of a two day supply of fresh food and 7 day supply of non-perishable food. Snacks are available and easily accessible to clients. Knives and sharp objects were observed to be stored in a locked cabinet and inaccessible to residents in care. Medications are stored in the office in a locked cabinet and are inaccessible to residents in care.

The bedrooms are double occupancy and contained lamps, chairs, dressers, and night stands for the convenience of residents.
Continued on LIC809C...
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: HANA HOU ALLIANCE
FACILITY NUMBER: 397202974
VISIT DATE: 08/18/2022
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The bathrooms were observed to have grab bars next to the toilets and non slip mats in the bathtub. The water temperature in the bathroom measured 122 degrees.

No clients were at the facility at the time of visit. 2 staff members were scheduled for a later shift on this day. 2 staff files were reviewed and were found to be in complete.

The facility was determined to be in substantial compliance and no deficiencies were cited today from either the Health and Safety Code or the California Code of Regulations.

An exit interview was conducted and copy of this report was emailed to the Administrator and Licensee.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC809 (FAS) - (06/04)
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