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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480109899
Report Date: 06/01/2023
Date Signed: 06/02/2023 10:42:35 AM

Document Has Been Signed on 06/02/2023 10:42 AM - 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:HARRISON HOME CAREFACILITY NUMBER:
480109899
ADMINISTRATOR:HARRISON, WILMAFACILITY TYPE:
735
ADDRESS:390 SAWYER STREETTELEPHONE:
(707) 643-4853
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Mario GrayTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Araceli Canela conducted an unannounced Annual Required – 1 yr. inspection. LPA was greeted by House Manager, Mario Gray (MG). The facility currently provides care for 5 clients, and it is licensed for 6 clients, of which 2 may be non-ambulatory.

LPA toured facility and found it at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be charged and serviced on 5/22/23. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Toxins are stored in a locked cabinet in the facility kitchen. LPA tested facility smoke alarms and found them to be in working condition. Medications are kept in a secured cabinet located in the kitchen. There was a supply of hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. LPA found facility staff have proof of 1st Aid & CPR. Water temperature read 107 degrees F. and within the required 105-120 degrees F.
Staff and resident files were in compliance.

Licensee/Administrator to submit updates of the following documents by 6/30/2023.
· Copy of Administrator Certificate
· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond (If applicable)
· LIC 610 Emergency Disaster Plan
· LIC 9020 Register of Facility Clients
· Infection Control Plan of Operation (If changes)
No citations issued during todays visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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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