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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803967
Report Date: 05/17/2024
Date Signed: 05/17/2024 01:57:13 PM

Document Has Been Signed on 05/17/2024 01:57 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:LONGSPUR MANORFACILITY NUMBER:
486803967
ADMINISTRATOR/
DIRECTOR:		FERNANDEZ, ASHLEYFACILITY TYPE:
735
ADDRESS:1107 LONGSPUR DRTELEPHONE:
4159394491
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 4DATE:
05/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Zaireene Lopez, House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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At approximately 8:49 AM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced Annual and was greeted by Emoni Norman, Lead DSP. Zaireene Lopez, House Manager (HM)arrived shortly after. At approximately 9:00AM, LPA and HM toured the building and grounds which was found to be clean. Facility was not found in good repair. LPA observed white repair patches on walls in shared female bathroom, family room, and the hallway that are unpainted. Per HM, shared female bathroom was recently patched up and C1 caused another hole in the same area. LPA advised HM facility must be kept in good repair at all times per regulation. LPA observed all walkways and exits to be unobstructed. LPA observed inner gate is slightly dragging on the ground, making it difficult to open. Advised HM all gates are to be working and in good repair. The amount of fresh and non-perishable foods was within regulation. Emergency food and water containers are located in the garage. LPA advised HM all food must be properly stored per regulation. Per HM, clients have their own shelves to store food and C2 gets triggered when food is touched by anyone else. C2 prefers chips to remain open. Advised HM to take precautions on pest control. Toxins are secure and not accessible to clients. Toxins are located and locked in the Laundry Room and Hallway. Medication is centrally stored and secure in the locked closet. There is a sufficient supply of hygiene products and linens on hand for client use. Mattress pads were in place or available for Client use. Water temperature measured within regulation between 109.2 and 110.2 degrees F at three out of three faucets accessible to clients. One of one Fire extinguishers were charged and inspected on 06/20/2023. Six out of six smoke detectors and four out of four carbon monoxide detectors were tested and found to be in working order. Two of four clients were at day program. Two of four clients do not attend day program and were at home. C3 and C4 requested to not have their rooms inspected. Disaster Drills are conducted quarterly with the last drill conducted 04/18/2024.

Continued on 809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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 6
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: LONGSPUR MANOR
FACILITY NUMBER: 486803967
VISIT DATE: 05/17/2024
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Continued from 809

Based on LPA observations and conversations with C3 and C4, clients are very happy and enjoy the family atmosphere. A community atmosphere is encouraged with weekly community outings including a planned community outing to Off The Grid in San Francisco this afternoon.

At approximately 11:00AM, LPA reviewed 4 of 4 Client records and 5 of 11 Staff records, which were all found to be well organized. 3 out of 5 staff files do not contain LIC 503 and TB test results. Per HM requesting documentation from HR. Advised HM documents must be on site and available for CCL LPA to review at all times. HM will submit LIC 503 and TB test results for S1, S2,and S3 to CCL as soon as documents are received by HR/RO. First aid and CPR certification were current in staff files reviewed. P&I monies were documented, secure and not commingled. Administrator Certificate 09/15/2025

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC 503
TB Test
Surety Bond
Infection Control Plan (If changes)

Updated copies of the following documents were received during visit to update facility file:
Staff Schedule
LIC610D- Disaster Plan



No deficiencies cited during this inspection
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
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