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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804021
Report Date: 12/01/2023
Date Signed: 12/01/2023 12:23:54 PM

Document Has Been Signed on 12/01/2023 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:WALK OF LIFE RESIDENTIAL CARE ARFFACILITY NUMBER:
486804021
ADMINISTRATOR:LANDAS, JENNIFERFACILITY TYPE:
735
ADDRESS:3124 MUSE WAYTELEPHONE:
(707) 439-1816
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 1DATE:
12/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Rolando Manasla, Lead StaffTIME COMPLETED:
12:40 PM
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On 12/1/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Lead Staff, Rolando Manansla. The facility currently provides care for 1 client, who was attending day program at the time of visit. LPA continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 1/26/2023. Smoke and carbon monoxide detectors were interconnected found throughout the facility, tested and to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. Water at faucets accessible to clients was measured between 107.0 and 111.2 degrees F which is within Title 22 Regulations.

Facility conducts and records emergency disaster drills on a monthly basis. Medications are located in a designated cabinet in the kitchen area and found to be secured. A spot medication count was conducted for client and found to be in order along with properly documented centrally stored medication records. LPA conducted a review for staff files and found all staff to have 1st Aid & CPR certification and annual training on file. In addition, LPA reviewed client record and found all documents including Needs & Service Plan, North Bay Regional Center Individual Program Plans and Physician's Reports to be current. Client attending day program is currently provided transport to and from the facility directly from the day programs. There is a sufficient supply of linens, hygiene product and paper products available for client use.

In addition, LPA conducted a follow up on an incident report involving client C1 in a physical altercation with another house mate C2. The facility has been in contact with NBRC and C2's family determining that C2 is not compatible with the facility. LPA was informed that C2 was found other placement and has been safely relocated.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WALK OF LIFE RESIDENTIAL CARE ARF
FACILITY NUMBER: 486804021
VISIT DATE: 12/01/2023
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Administrator, Jennifer Landa's Administrator Certification 60059086735 is current through 3/22/2025.

LPA requested the following documents be sent to CCL by COB 1/1/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Proof of ownership/Control of Property

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC809 (FAS) - (06/04)
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