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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801821
Report Date: 06/25/2024
Date Signed: 06/25/2024 12:23:03 PM


Document Has Been Signed on 06/25/2024 12:23 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:ANN'S CARE HOMEFACILITY NUMBER:
486801821
ADMINISTRATOR:BEST, DEBRA ANNFACILITY TYPE:
740
ADDRESS:124 DELTA CIRCLETELEPHONE:
(707) 643-3363
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:5CENSUS: 0DATE:
06/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Debra Ann Best, LicenseeTIME COMPLETED:
12:30 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
On 6/25/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Licensee, Debra Ann Best. The facility currently has 0 residents admitted. The Licensee is in the process of conducting assessments with potential clients for possible admission within the next month.

LPA continued with a tour of the facility with Licensee, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found to be charged on 10/23/2023. Smoke and carbon monoxide detectors found throughout the facility, were tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings. LPA reviewed staff training and found it to be in order, facility is currently halfway through staff annual training with plans of completing by the end of the year. In addition, staff 1st aid and CPR training on file and up to date.

Cleaning supplies and other toxins are safely stored in locked cabinets in the garage and under kitchen sink, all of which were secured upon inspection. Sharps and other kitchen supplies that could pose danger if available to residents were found secured. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Water at faucets accessible to residents were measured at 109.5 degrees F which is within regulation. There is one primary emergency exit located in the backyard which were found to be unobstructed. There is an outdoor patio with shade and large outdoor space for residents to utilize with exits equipped with ramps for accessibility. No deficiencies cited during today's visit.

Licensee, Debra Best's Administrator Certificate 7006809740 is valid through 11/22/2024.
LPA requested the following documents be sent to CCL by COB 7/25/2024:

LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan Liability Insurance
Control of Property/Rental Agreement
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024
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 1