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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804121
Report Date: 01/17/2024
Date Signed: 01/17/2024 12:45:11 PM


Document Has Been Signed on 01/17/2024 12:45 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:TREE DUCK RESIDENTIAL CAREFACILITY NUMBER:
486804121
ADMINISTRATOR:GAWAT, HAZEL MAEFACILITY TYPE:
740
ADDRESS:800 TREE DUCK WAYTELEPHONE:
(707) 688-7512
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:6CENSUS: 4DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:caregiverTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 1/17/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator was unable to assist. Inspection conducted with designee Randy Leysa.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is very clean and residents' care needs appear to be met.
There is required food supplies, water temperature is within required range and potentially dangerous products are properly secured.
LPA advised that the fire door to resident rooms not be obstructed by a door stop, the staff room in the garage is not on the facility sketch- this will be resolved with the regional office.

LPA reviewed 4 resident files. Files are complete and well organized. Some minor corrections were made to resident files.

LPA reviewed 3 staff files. Files are complete. Staff are finger print cleared, health screen cleared and have current 1st aid/ cpr certification. Electronic training records were not available while LPA was present. Licensee will email LPA proof of staff training.

Copies liability ins. certificate to be be submitted when renewed.

Admin arrived to review.
No deficiencies are being cited as a result of todays inspection. Exit interview conducted with licensee and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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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