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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108916
Report Date: 11/16/2023
Date Signed: 11/16/2023 01:33:11 PM

Document Has Been Signed on 11/16/2023 01:33 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:SARAH'S COUNTRY HOMEFACILITY NUMBER:
490108916
ADMINISTRATOR:NAVARRO, LORAFACILITY TYPE:
735
ADDRESS:341 MILLBRAE AVENUETELEPHONE:
(707) 585-0607
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 4DATE:
11/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Lora Navarro (Administrator)TIME COMPLETED:
01:48 PM
NARRATIVE
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Licensing Program Analyst (LPA), Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Administrator Lora Navarro. Three clients were present during the visit engaged in activities.

LPA/Administrator initiated a tour of the facility at 11:30am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Extra hygiene products and linens were available. Cabinet 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 last inspected September, 2023. Smoke detectors located throughout the facility were tested and operational. Carbon monoxide detector was tested and operational. Most recent fire/disaster drill was conducted November 7, 2023. Required postings were observed. Water temperature in client bathrooms read at 129. and 123.6 which are not within regulation of 105 & 120 degrees F. Contact information was reviewed.

File review was initiated at 12:00pm. Three staff files and four client files were reviewed. Staff have required First Aid/CPR certificates and required annual training hours. Administrator Certificate for Lora Navarro, 6017813735, expires on 7/25/2024. Medications and medication records were reviewed. Cash resources records were reviewed. Administrator provided updates of the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Emergency Disaster Plan (LIC610E).
No deficiencies cited during today's visit. Exit interview conducted with Administrator Lora Navarro. A copy of this report was provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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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Document Has Been Signed on 11/16/2023 01:33 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/16/2023 at 01:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SARAH'S COUNTRY HOME
FACILITY NUMBER: 490108916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (2) Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 of 2 resident bathrooms. The hot water measured above regulation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Licensee immediately turned hot water heater down. Licensee will submit a 7 day log of daily water temperatures showing temperature is within regulation. 7 Day log to be submitted 11/21/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
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