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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490104221
Report Date: 12/19/2022
Date Signed: 12/19/2022 04:21:04 PM

Document Has Been Signed on 12/19/2022 04:21 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:WHISTLER HOUSE, THEFACILITY NUMBER:
490104221
ADMINISTRATOR:HARTWIG, TERRY LYNNFACILITY TYPE:
735
ADDRESS:4642 WHISTLER AVENUETELEPHONE:
(707) 585-0606
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 4CENSUS: 3DATE:
12/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Terry L Hartwig (Licensee)TIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee Terry L Hartwig. The inspection is based on Infection Control practices of this facility.

Upon arrival, LPA was screened by staff for Covid-19 which included a temperature check and signing in. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE and have been N95 fit tested. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication and incontinence care. Fire extinguisher was last serviced October 11, 2022 along with Smoke Detectors and Carbon Monoxide detector by the Sonoma County Fire Department. Last disaster drill was conducted on September, 2022.

Licensee provided copies of the following documents: LIC 308 Designated Administrator, LIC 610 Emergency Disaster Plan, LIC400 affidavit regarding client cash resources, surety bond and LIC 500 Personnel Summary.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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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