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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490104221
Report Date: 01/26/2024
Date Signed: 01/26/2024 10:18:13 AM

Document Has Been Signed on 01/26/2024 10:18 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: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:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Terry L Hartwig (Licensee)TIME COMPLETED:
10:33 AM
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Licensing Program Analyst, (LPA) Cuadra, arrived unannounced to conduct an Annual Required Inspection and met Licensee Terry Hartwig. Clients were attending to day program at the time of visit.

LPA/Licensee initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client bedrooms and shared bathroom are located in a unit separate from the house. There is an intercom system installed if clients need assistance. Client rooms were furnished per regulation. Extra hygiene products and linens were available. Water temperature in bathrooms used by clients measured at 105.2 degrees F. Cabinet located under the kitchen sink containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Fire extinguisher was fully charged and last inspection was August, 2023. Smoke detectors located throughout the facility and carbon monoxide detector were tested and operational. Most recent fire drill was conducted 1/4/2024. Cash resources reviewed. Annual fees are current. Contact information was reviewed.

File review was initiated at 9:00am. Two staff files and three client files were reviewed. Staff have required First Aid certificates. Administrator Certificate for Licensee/Administrator Terry Hartwig, 6021626735, expires on 12/18/24. Medications and medication records were reviewed.

Licensee submitted updates of the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), surety bond and Emergency Disaster Plan (LIC610E).

No deficiencies cited during this inspection. Exit interview conducted with Licensee and copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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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