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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108231
Report Date: 04/19/2022
Date Signed: 04/19/2022 04:09:40 PM

Document Has Been Signed on 04/19/2022 04:09 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:MARK J HURLEY HOUSEFACILITY NUMBER:
490108231
ADMINISTRATOR:FAIRCHILD, CARRIEFACILITY TYPE:
735
ADDRESS:2641 NEOTOMASTELEPHONE:
(707) 575-9805
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 6DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Exectutive Director, Sherri KimbellTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required-1 Year inspection at approximately 3:05 PM and met with Executive Director, Sherri Kimbell. The inspection is focused on the Infection Control procedures and practices of this facility.

At primary entrance LPA observed temperature logs and staff sign-in sheet. LPA conducted walk through of the facility with Sherri Kimbell and observed COVID postings throughout. Mitigation plan was received and reviewed by Community Care Licensing (CCL).

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Staff have completed Personal Protective Equipment (PPE) and infection control training. Staff were N95 fit tested at the beginning of the pandemic. High touch surface areas are disinfected daily. LPA confirmed facility has necessary PPE and supplies to support a resident in isolation. Facility currently has three bedrooms with two clients per bedroom. If client were to become ill there is plan in place to isolate clients.

Clients' emergency contact information has been updated and executive director confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked garage cabinet as well in locked cabinets in hallway. Medications are locked and inaccessible in medication room. All clients have received their first booster shot. Facility is currently conducting weekly surveillance testing for all staff.

Administrator on file no longer with the facility. Facility will submit application to designate a new administrator. LPA requested the following documents during the visit: LIC 308, LIC 500, LIC 610, LIC 9020

Exit interview conducted with executive director, and a copy of this report printed for the facility
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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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