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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108916
Report Date: 09/02/2021
Date Signed: 09/02/2021 01:30:20 PM

Document Has Been Signed on 09/02/2021 01:30 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SARAH'S COUNTRY HOMEFACILITY NUMBER:
490108916
ADMINISTRATOR:LAWRENCE, SARAHFACILITY TYPE:
735
ADDRESS:341 MILLBRAE AVENUETELEPHONE:
(707) 585-0607
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 5DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Lora Navarro (Administrator)TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator, Lora Navarro. LPA conducted a Risk Assessment call with Licensee, Sarah Lawrence prior to the visit. LPA/Administrator discussed about the importance of reviewing new PINs 21-40-ASC and 21-38-ASC for new guidance.

Upon arrival, LPA observed posters on the front door pertaining to Covid-19, LPA had their temperature checked and was screened at the entrance and entered into the sign-in sheet. Facility does document symptoms or temperatures of staff and residents. LPA provided a screening questions template for facility to screen and document temperatures and symptoms. LPA conducted a walk-through of the facility with the staff and observed Covid-19 posters throughout the facility including hand washing posters in bathrooms. Hand sanitizer is kept in the common area of the facility. Facility has multiple bathrooms that are kept stocked with hand hygiene products. Clients do not attend to Day Program. Facility has other activities for clients use.

Facility has submitted a mitigation program plan and it was approved on 4/29/21. Facility has PPE supplies accessible to staff. Facility has a 30-day supply of medication and incontinence care for clients. Clients do not typically wear masks inside the facility but have them available. Clients do however, wear masks while away from the facility. All staff had masks on during this visit. Facility has conducted staff training on infection control. Medications were centrally stored and locked. Facility has 100% vaccination rate for all staff and residents.

No deficiencies cited during today's inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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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