<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800549
Report Date: 02/09/2023
Date Signed: 02/09/2023 12:47:55 PM


Document Has Been Signed on 02/09/2023 12:47 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:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Charlene Alvarez-AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts(LPA), Alviso conducted a Required 1-Year inspection, on 2/9/2023 at approximately 11:30am, and met with Licensee/Administrator Charlene Alvarez. Today's inspection will be focused on the facility's infection control procedures.

All clients are at day program today; Currently there are five(5) residing in care. All staff have criminal record clearance as required. All staff had current First Aid and CPR as required. Administrator submitted the required infection control plan for the facility's plan of operation.
LPA toured the facility with the Administrator. The home was clean and orderly.
The fire extinguisher was serviced and tagged as required- expires 10/26/23.
All common areas, hallways, bathrooms, and resident rooms had sufficient lighting for resident use. Facility had a sufficient supply of perishable and nonperishable food. Facility had a sufficient supply of hygiene products, paper products, and cleaning supplies. Medications were locked and inaccessible to residents in care. Toxins were locked and inaccessible from residents in care.

LPA is requesting the following documents be updated and submitted by 2/16/23:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
610 Emergency Disaster Form
Copy of current -Emergency Disaster Plan (ensure to provide all information in all boxes as required)
Copy of LIC400 Handling of Client Cash Resources, include copy of surety bond.
Copy of Current Liability Insurance
Copy of current Administrator Certificate

No deficiencies cited today.
Exit interview conducted with Licensee/Administrator Charlene Alvarez.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1