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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804242
Report Date: 09/11/2024
Date Signed: 09/11/2024 11:41:57 AM

Document Has Been Signed on 09/11/2024 11:41 AM - 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:CARE HOME AT LAWLER RANCH, THEFACILITY NUMBER:
486804242
ADMINISTRATOR/
DIRECTOR:		ADRIANO, RONMARKFACILITY TYPE:
740
ADDRESS:237 LAWLER RANCH PARKWAYTELEPHONE:
(707) 759-3572
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY: 6CENSUS: 4DATE:
09/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Ron-Mark Adriano, Administrator TIME VISIT/
INSPECTION COMPLETED:
11:41 AM
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived on 09/11/2024 for the purpose of conducting a Pre Licensing Inspection. LPA was met at the front door by care staff and granted access to the facility; Administrator Ron-Mark Adriano arrived shortly. There were 2 care staff at the time of inspection and there were 4 residents in care. Fire Clearance approved for 6 with 5 being non-ambulatory in any room; hospice waiver for 5. Ron-Mark Adriano will be the Administrator, Administrator's Certificate # 7024492740, effective 02/26/2023 - 02/25/2025.

LPA and Administrator toured the one story facility, which has 5 bedrooms, 2 bathrooms, and family room/ dining area and kitchen. LPA observed the facility to be clean and at a comfortable temperature of 74 degrees F with all exits free from obstruction. LPA found the 2 carbon monoxide detector to be operational during the inspection. The 2 fire extinguishers were last serviced on 03/29/2024 and fully charged and operational. First Aid kit was inspected and found to be complete. Water temperature was 112.2 - 114.6 degrees F and is within acceptable range of 105 to 120 degrees F. There were sufficient perishable and non-perishable foods located in the kitchen. Knives and other hazardous items were locked and inaccessible to residents in care. Medications are locked in cabinet in living room where it is inaccessible. Cleaning products and other toxins are locked in laundry room and locked cabinet in garage and inaccessible to residents in care. There was a supply of linens, cleaners, hygiene products and paper products available for residents. Bathrooms were supplied with paper towels and hand soap, and outfitted with grab bars and non-slip floors/mats. A tour of all resident bedrooms was conducted, and bedrooms inspected have lighting and appropriate furnishing.
(Report continued on LIC 809C)
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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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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: CARE HOME AT LAWLER RANCH, THE
FACILITY NUMBER: 486804242
VISIT DATE: 09/11/2024
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 LPA discussed the Emergency Disaster Plan in detail. Licensee has a supply of water and non-perishables. Facility has a supply of PPE.

A review of staff and resident files were found to be complete. Medication records were in order, and medications are disposed of properly as needed.

Component III was conducted with Administrator. Licensee has attended the Component III during pre-licensing inspection for another facility.

LPA found no deficiencies at the facility at the time of inspection.

Exit interview was conducted, and a copy of this report was given to the Administrator. LPA will forward this report to the Licensing Program Manager and assigned Application Analyst in our Department.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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