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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801461
Report Date: 12/07/2023
Date Signed: 12/07/2023 02:01:51 PM

Document Has Been Signed on 12/07/2023 02:01 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:DANA'S FAMILY HOMEFACILITY NUMBER:
486801461
ADMINISTRATOR:THOMAS, DANAFACILITY TYPE:
735
ADDRESS:855 PALERMO DR.TELEPHONE:
(707) 438-7397
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 4DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Care Staff and Administrator via phoneTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an annual inspection on 12/7/2023 and was allowed access to the facility by staff. There were 2 staff members at the time of inspection. Administrator was contacted by phone; currently off-site due to family matter.

There are currently 4 clients residingn at the facility and they receive services from North Bay Regional Center. The facility operates with 24 hour staffing.

LPA toured the facility with staff and made the following observations: LPA observed signs posted to promote droplet precaution at the entrance of the facility. There was also a sign-in sheet for visitors.

Facility was found to be at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be charged and inspected 11/27/23. The carbon monoxide and smoke detectors were tested were working. LPA observed that the toxins that were stored under the sink were locked and in- accessible to residents in care. The medication cabinets were locked and inaccessible. The exterior grounds were clear of debris and the patio provided a covered seating area for residents.

The staff and residents were decorating the facility for the holidays, and residents were excited about the Christmas tree.

LPA will return at later date to complete inspection of records.
There were no deficiencies or citations issued at this time.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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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