397202974-8-22-2023-27-AS-RCAL-CUXSH2-20230822135250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397202974
Report Date: 08/22/2023
Date Signed: 08/22/2023 01:54:11 PM

Document Has Been Signed on 08/22/2023 01:54 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	HANA HOU ALLIANCE		FACILITY NUMBER:	397202974
ADMINISTRATOR:	MARRIOTT, ANNE		FACILITY TYPE:	735
ADDRESS:	12005 E. LOCKE ROAD		TELEPHONE:	(209) 727-3991
CITY:	LOCKEFORD	STATE: CA	ZIP CODE:	95237
CAPACITY: 6		CENSUS: 6	DATE:	08/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Kim Contrevo, Administrator		TIME COMPLETED:	02:15 PM

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On 08/22/23, Licensing Program Analyst (LPA) Renee Campbell arrived at the facility at approximately 8:30 am. LPA Campbell was met by Kim Contrevo, Administrator and Nadine Holman Direct Support Personnel (DSP). LPA Campbell arrived to facility to see a one story brick building. The backyard could be seen through a breezeway in the middle of the building. The pool entrance was locked and surrounded by a 6 foot gate on the right. Upon entry to the home, LPA Campbell observed the living room and the entrances to the resident area and the office and began to tour the facility.

The administrator lead LPA Campbell to the dining room where there was a floor to ceiling glass window and a back door to the backyard. No residents were immediately visible. The backyard had chairs and picnic tables under the shade of the house and trees. A garden was also present to the right. The kitchen contained a refrigerator with enough perishables for 2 days. Knives and toxins were locked away from residents. In the laundry room, there was a washer and dryer and a refrigerator. Detergent, and other cleaners were locked in the closet in the laundry room as well. While touring the resident area, LPA Campbell saw that two residents were napping in their rooms.

An outbuilding casita was available for guests, zoom meetings and as an additional bathroom for residents or staff. There are no live in staff. It contains a kitchenette with a refrigerator for large overflow items. The bedroom contained drawers and an unmade mattress wrapped in plastic. One of the residents allowed LPA Campbell to view the room he shares with his wife. It contained a closet, a chest of drawers and a desk as well as a night stand.

During the tour of the pool area, LPA Campbell observed cleaning nets as well as surrounding fences for the pool that were over 7 foot high.. The Administrator later provided Water Emergency Training certificates for all personnel.

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HANA HOU ALLIANCE	FACILITY NUMBER: 397202974
	VISIT DATE: 08/22/2023

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The temperature of the facility was observed to be 74 degrees Fahrenheit and the water in the bathroom was measured at 122 degree Fahrenheit and was accompanied by a sign that stated, "Warning: Hot Water". This facility is licensed for 5 ambulatory and 1 non-ambulatory, developmentally disabled adults, 18 to 59 years old. Of the 12 staff files available, LPA Campbell reviewed 3 of them and of the 6 resident files, LPA Campbell reviewed 2 resident files. The fire extinguishers were last inspected on 11/07/2022. Both carbon monoxide and smoke alarms were tested and found to be functional. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308)
Personnel Report (LIC500)
Administrator Certificate

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Exit interview held, copy of report given

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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