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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108231
Report Date: 06/15/2023
Date Signed: 06/15/2023 03:04:11 PM

Document Has Been Signed on 06/15/2023 03:04 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:
06/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Direct Support Professional (DSP), Erin Essary
Licensee, Sherry Kimball
Administrator, Catherine Brenegan		TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Mark J Hurley House for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by DSP, Erin Essary. Licensee, Sherry Kimball arrived 1 hour later. Administrator arrived 1 hour and 15 minutes later.

LPA toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on June 2023 at the time of the inspection. First Aid closet was fully stocked and appropriate during the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Water temperature in 1 of 1 clients bathrooms measured at 110 degrees and is within acceptable range of 105 to 120 degrees F. Staff Water temperature measured at 110 degrees in 1 of 1 staff bathroom, and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Food menu was observed during the inspection. There are special provisions made for individuals with special dietary needs. Medications were centrally stored and locked. Medication Orders were reviewed and found to be appropriate during the Required 1 year inspection. Cleaning products and other toxins are located in the garage that was locked and inaccessible to clients in care at the time of the inspection. There was a supply of Linens, cleaners, hygiene products and paper products available for clients. All bathrooms designated for clients in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats. A tour of all clients bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. The Infection Control Plan was not discussed due to the facility not having the most updated Infection Control Plan (See LIC 9102-Technical Assistance). LPA emailed the Infection Control Plan Template. LPA reviewed the Emergency Disaster Plan with the Administrator. Quarterly Disaster Drill document was reviewed and the facility conducted the Quarterly Disaster Drill on May 15, 2023 with all staff on duty. (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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: MARK J HURLEY HOUSE
FACILITY NUMBER: 490108231
VISIT DATE: 06/15/2023
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LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

During the Required 1 year inspection, LPA reviewed staff files. LPA found 1 out of 4 staff files to not have the 16 hours of Required Initial training as outlined in regulation (See LIC 9102-Technical Assistance). LPA conducted staff interviews with 4 of 4 staff members. LPA reviewed the Administrator Certificate for Administrator, Catherine Brenegan and found that to be appropriate during the inspection (Administrators Certificate #: 6065221735 issued on January 24, 2023 with an expiration of August 27, 2025). First Aid Training was found in all staff files and were appropriately valid during the Required 1 year inspection. Client files were reviewed and found to be appropriate during the inspection. Clients were interviewed.

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308-Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Liability insurance
Control of Property
Register of clients

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the facility Licensee.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
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