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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800668
Report Date: 07/15/2022
Date Signed: 07/15/2022 03:07:49 PM

Document Has Been Signed on 07/15/2022 03:07 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 ADULT RESIDENTIAL CAREFACILITY NUMBER:
496800668
ADMINISTRATOR:GREGORI, LINDSEYFACILITY TYPE:
735
ADDRESS:3030 TERRA LINDA DRIVETELEPHONE:
(707) 527-8990
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 3DATE:
07/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Direct Support Staff Sandra KruseTIME COMPLETED:
03:17 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Direct Support Staff Sandra Kruse. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed posters outside notifying visitors that mask must be worn in the facility. Once inside, LPA observed a screening station near the entrance along with a visitor sign in. LPA confirmed with Direct Support Staff that facility is conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. LPA discussed disinfecting commonly touched services more frequently, at least once per day. Facility maintains documentation of staff and client daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation inside per CCL guidance. Facility continues to train staff on PPE and infection control. LPA and Direct Support Staff discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced November 2021. Smoke and carbon monoxide detectors throughout facility were tested and operational.


Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ADULT RESIDENTIAL CARE
FACILITY NUMBER: 496800668
VISIT DATE: 07/15/2022
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Continued from LIC809C

Direct Support Staff and LPA discussed their Emergency Disaster Plan. Infection Control Plan is completed and will be sent to LPA.

Licensee/Administrator to submit updates of the following documents by 8/15/2022:
LIC 308 Designated Administrator
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond
LIC 610 Emergency Disaster Plan (if any changes)
LIC 9020 Register of Facility Client’s/Resident’s

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

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC809 (FAS) - (06/04)
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