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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108231
Report Date: 05/31/2024
Date Signed: 05/31/2024 01:23:56 PM

Document Has Been Signed on 05/31/2024 01:23 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MARK J HURLEY HOUSEFACILITY NUMBER:
490108231
ADMINISTRATOR/
DIRECTOR:		BRENEGAN, CATHERINEFACILITY TYPE:
735
ADDRESS:2641 NEOTOMAS AVENUETELEPHONE:
(707) 575-9805
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:44 AM
MET WITH:Catherine Brenegan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:38 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Michael Lancaster, House Manager (HM). Catherine Brenegan, Administrator arrived later as well. Facility contact information was reviewed.

At approximately 10:00am LPA and HM toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Water temperature in sink accessible to residents in care measured at 113.5 and 112.6 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 5/10/24. Smoke/Carbon Monoxide detectors located throughout the facility were operational as indicated by the Santa Rosa Fire Equipment service tag dated July 2023. Facility’s last quarterly disaster drills were conducted on 12/12/2023. Facility has a backup generator for use during a power outage.

At approximately 10:30am LPA conducted a review of 6 resident records. All required documentation present.

At approximately 11:30am LPA conducted review of 5 staff records. All required documentation present.

At approximately 12:00pm LPA and HM conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies

Continued on 809C...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MARK J HURLEY HOUSE
FACILITY NUMBER: 490108231
VISIT DATE: 05/31/2024
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Continued from 809...

At approximately 1:00pm LPA and HM reviewed cash resources.

Catherine Brenegan Administrator Certificate 6065221735 expires 8/27/2025. Fees are now due and LPA gave LIS print out to Admin with PIN for payment.



LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Surety Bond

No deficiencies cited during this inspection. Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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