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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108916
Report Date: 11/08/2024
Date Signed: 11/08/2024 02:19:20 PM

Document Has Been Signed on 11/08/2024 02:19 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/
DIRECTOR:		NAVARRO, LORAFACILITY TYPE:
735
ADDRESS:341 MILLBRAE AVENUETELEPHONE:
(707) 585-0607
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 4DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:34 PM
MET WITH:Lora Navarro (Administrator)TIME VISIT/
INSPECTION COMPLETED:
02:34 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. Annual fees are current. Required postings were observed.

LPA/Administrator initiated a tour of the facility at 12:45 pm 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 August 3, 2024. Water temperature in client bathrooms read at 111.6. and 108.2 which are not within regulation of 105 & 120 degrees F. Contact information was reviewed.

File review was initiated at 1:00pm. 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, expired on 7/25/2024. LPA reviewed the department's certification unit active/pending lists and was unable to find their name on it. LPA provided Administrator with their contact information to follow up (technical violation issued). Medications and their records were reviewed. Cash resources records were reviewed.

Administrator provided updates of the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Surety bond will be sent to CCL by not later than 11/15/24.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency may result in a civil penalty assessment. Exit interview conducted with Administrator and copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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 11/08/2024 02:19 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/08/2024 at 02:09 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: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation, the Administrator did not comply with the section cited above in 1 out of 1 fire extinguisher was not serviced since May 5, 2021 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Administrator agreed to submit Proof of Correction (POC) that fire extinguisher have been serviced and charged by a fire extinguisher service company or the Fire Department by POC due date 11/15/24.
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: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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