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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800549
Report Date: 03/25/2022
Date Signed: 03/25/2022 12:16:22 PM

Document Has Been Signed on 03/25/2022 12:16 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:ALVAREZ FAMILY HOMEFACILITY NUMBER:
496800549
ADMINISTRATOR:CHARLENE ALVAREZFACILITY TYPE:
740
ADDRESS:2185 FLORAL WAYTELEPHONE:
(707) 545-6464
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 5DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:CHARLENE ALVAREZ-ADMINISTRATORTIME COMPLETED:
12:20 PM
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Licensing Program Analyst, (LPA) Dina Alviso, arrived unannounced to conduct a Required-1 Year inspection and met with Licensee/Administrator Charlene Alvarez. The inspection is focused on the Infection Control procedures and practices of this facility.

Mitigation plan was received, and reviewed by the Department. Fire clearance is approved for 3 ambulatory, and 3 non-ambulatory residents. Fire extinguishers were tagged and inspected as required- expires 11/15/2022.
The five (5) clients were attending day program during this inspection. All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened daily, and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents in care. All exit alarms were on exit doors and working properly. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Residents have masks available to them for their use if needed and/or wanted. Administrator stated that staff wear masks in the facility, and also when providing care services to the residents in and out of the facility. Administrator had a mask on during the LPA's inspection. During the inspection, two women arrived to clean the facility as scheduled, and both were screened and masked upon entry.
No deficiencies found in the areas inspected.
No citations issued.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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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