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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111817
Report Date: 09/11/2023
Date Signed: 09/11/2023 04:22:12 PM

Document Has Been Signed on 09/11/2023 04:22 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:LAUGHLIN COUNTRY HOMEFACILITY NUMBER:
490111817
ADMINISTRATOR:LA DOW, JEFFFACILITY TYPE:
735
ADDRESS:2565 LAUGHLIN ROADTELEPHONE:
(707) 576-1409
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 5DATE:
09/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator, Jeff La DowTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Victoria Bertozzi and Helena Rummonds arrived unannounced to conduct an Annual Required inspection and met with Administrator, Jeff La Dow.

Upon arrival, LPAs initiated a tour of the facility around 1:10PM and made the following observations: Facility was at a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature measured at 107 and 118 degrees F, in respective bathrooms which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cleaning supplies and disinfectants are stored locked and inaccessible to clients in garage. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility has emergency food and water supplies.

Fire extinguishers were last inspected April 2023. Facility has Smoke and Carbon Monoxide detectors located throughout the facility that were tested and in working condition. Most recent fire drill and disaster drill was conducted April 2023. LPA reminded Licensee that fire and disaster drills are to be conducted quarterly.

Three staff files and five client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator Jeff La Dow expires 04/12/2024. Medications and medication records were reviewed. Client cash resources were also reviewed. LPAs conducted staff and client interviews.
Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LAUGHLIN COUNTRY HOME
FACILITY NUMBER: 490111817
VISIT DATE: 09/11/2023
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Continued from LIC809

Licensee/Administrator to submit updates of the following documents by 10/11/2023:


LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC809 (FAS) - (06/04)
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