<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800471
Report Date: 05/14/2024
Date Signed: 05/16/2024 10:05:21 AM

Document Has Been Signed on 05/16/2024 10:05 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MARGARETS FAMILY HOMEFACILITY NUMBER:
486800471
ADMINISTRATOR/
DIRECTOR:		MROZ, MARGARETFACILITY TYPE:
735
ADDRESS:566 FIESTA CT.TELEPHONE:
(707) 421-0714
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 2DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Margaret Mroz, LIcensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 9:00AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Margaret Mroz, LIcensee/Administrator. Facility is an Adult Residential Facility with Developmentally Disabled Clients in care. LPA was informed that there are 2 clients in care and both were away at their day programs.

At approximately 9:05AM, LPA initiated a tour of the facility and observed the following: Facility is a two-story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. There is outdoor space for activities. There is a pool in the backyard, which is gated and locked. There are two sheds in the back yard, which were observed to be used for storage and projects, and both were locked. LPA observed puzzles and a supply of games for clients. Licensee states that clients attend outings and go on vacations with her and her family, as well as with New Directions, an organization that coordinates all inclusive trips domestically and internationally for developmentally disabled individuals. .

The facility is hardwired. Fire extinguisher was last serviced March 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular disaster drills bi-annually, and the most recent drill was conducted January 2024. LPA advised Licensee that drills shall be conducted quarterly moving forward. LPA observed the facility's infection control plan, first aid kit, and emergency disaster plan. LPA observed an emergency supply of water, PPE, and emergency supplies. Licensee states facility has a back-up generator if one is needed.

Continued on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MARGARETS FAMILY HOME
FACILITY NUMBER: 486800471
VISIT DATE: 05/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809

At approximately 9:45AM 3 staff files and 2 client files were reviewed. All staff have required First Aid certificates. Each has current CPR certification as well. LPA observed that staff have all the required paperwork in their files. 2 of 2 client files had all the required paperwork per regulation, except 1 client's file was missing a consent for emergency medical treatment. Licensee was advised to have the client sign one. Licensee will follow up on this with client's social worker. LPA observed up-to-date weight tracking logs and medical and dental visit logs for both clients. Outing and vacations were observed logged in client's records. Medications are centrally stored and locked. LPA reviewed medications and medication records which are maintained in compliance with regulation. LPA reviewed P&I monies and logs, which were organized and maintained according to regulation.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 10 days of this visit:

LIC500- Personnel Report

Exit interview conducted with Licensee whose signature on this document confirms receipt. No Deficiencies were cited. This report was reviewed with Licensee.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2