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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801461
Report Date: 01/29/2025
Date Signed: 01/29/2025 04:08:38 PM

Document Has Been Signed on 01/29/2025 04:08 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:DANA'S FAMILY HOMEFACILITY NUMBER:
486801461
ADMINISTRATOR/
DIRECTOR:		THOMAS, DANAFACILITY TYPE:
735
ADDRESS:855 PALERMO DR.TELEPHONE:
(707) 438-7397
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 4DATE:
01/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Dana Thomas, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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At approximately 2:50 PM, Licensing Program Analysts (LPAs) Julie Florio and Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection. Facility is an Adult Residential Facility (ARF) with four (4) ambulatory clients in care. All clients were present during today's visit. Facility is vendorized with North Bay Regional Center (NBRC).

At approximately 3:00 PM, LPAs initiated a tour of the facility with Administrator and observed the following: Facility is a one 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. LPAs observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have all of the 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 food and one week of non-perishable foods, as well as an emergency water supply. Medications were observed centrally stored and locked. There is outdoor space for activities in the backyard. LPAs observed a locked rear fence gate and informed Administrator that it shall be replaced with a latch lock to bring the facility into compliance with regulation. Administrator agreed to have this fixed immediately. Facility conducts community outings, and has puzzles, crafts, manicure/pedicure supplies and movie nights for the clients. LPAs were informed that facility does not have a designated internet access device available to clients in care. Administrator agrees to purchase one in order to bring the facility into compliance with regulation. Facility has internet available to clients in care and the phone was tested an operational during today's inspection.

Facility's fire extinguisher was observed charged and was last serviced 11/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills, and the most recent drill was conducted 5/2024. Administrator was informed that drills shall be conducted on a quarterly basis to remain in compliance with regulation.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: DANA'S FAMILY HOME
FACILITY NUMBER: 486801461
VISIT DATE: 01/29/2025
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Continued from LIC809...

Administrator agrees to conduct a drill before LPAs return to complete this annual inspection. LPAs observed facility's infection control plan and emergency disaster plan which was last updated 8/2023. Administrator agrees to update the facility's emergency disaster plan to bring the facility back into compliance with regulation. LPA observed a supply of PPE, emergency supplies, multiple first aid kits, and flashlights for emergency preparedness. Administrator states the facility does not have a backup generator.

LPAs will return at a later date to complete the annual inspection. LPAs will review resident files, staff files, medications and medication logs, as well as P&I during that visit.

No deficiencies were cited during inspection.

Exit interview conducted with Administrator whose signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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