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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800549
Report Date: 03/04/2025
Date Signed: 03/04/2025 12:10:46 PM

Document Has Been Signed on 03/04/2025 12:10 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:ALVAREZ FAMILY HOMEFACILITY NUMBER:
496800549
ADMINISTRATOR/
DIRECTOR:		MUTUNGA, EMMAFACILITY TYPE:
740
ADDRESS:2185 FLORAL WAYTELEPHONE:
(707) 545-6464
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Emma Mutunga-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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Licensing Program Analyst (LPAs) Stevenson and Alviso conducted a Required- 1 Year inspection, on 03/04/2025 at approximately 8:50 am, and met with Administrator Emma Mutunga. The facility currently has four clients in care.
All clients are at day program today.

LPAs reviewed three (3) staff files. All staff have criminal record clearance as required. All staff had current First Aid and CPR as required. All staff had required annual training completed.

Per LPA’s record reviews and observation 3 of 4 clients need a signed Emergency Consent Form and 2 of 4 clients need a Appraisal and Service Needs plan signed. Administrator was asked to appraise and determine the needs and services of her clients.


Facility has a required infection control plan. Facility has a required emergency and disaster plan.

At approximately 10:00am LPsA toured the facility with the Administrator. The home was clean and orderly. Hot water was checked at 118.4F and 119.7F degrees. All exits were clear. The fire extinguisher were found to be fully charged. Facility has two carbon monoxide detectors- they were working properly during the inspection. All smoke alarms and carbon monoxide were working during the inspection. All common areas, hallways, bathrooms, and resident rooms had sufficient lighting for resident use.

Continued on LIC809C...
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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: ALVAREZ FAMILY HOME
FACILITY NUMBER: 496800549
VISIT DATE: 03/04/2025
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Continued from LIC809

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. Bathroom had grab bars and non-slip mat for resident use.

Discussed proper storage of furnishings and beds not in use; administrator took away two beds in shed storage.

LPAs are requesting the following documents be updated and submitted by 04/05/2025
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Copy of LIC400 Affidavit Handling of Client Cash Resources
Copy of correct Surety Bond to cover your Client Cash Resources
Copy of Current Liability Insurance
Resident Roster


No deficiencies are cited today

Exit interview conducted with Administrator Emma Mutunga .Report signed and provided to the Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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