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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800668
Report Date: 09/11/2023
Date Signed: 09/11/2023 12:09:02 PM

Document Has Been Signed on 09/11/2023 12:09 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: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: 2DATE:
09/11/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator, Lindsay GregoriTIME COMPLETED:
12:20 PM
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Licensing Program Analysts (LPAs) Victoria Bertozzi and Helena Rummonds arrived unannounced to conduct a Case Management Annual Continuation inspection and met with Administrator, Lindsey Gregori.

LPAs returned to continue inspection that was initiated on 08/14/2023.

Upon arrival, LPAs conducted a tour of the facility around 8:50AM including the backyard, garage and kitchen. Bedrooms, living room, and other areas were toured during the previous inspection. LPAs made the following observations: Cleaning supplies were observed in an unlocked cabinet, accessible to clients in care. 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 does not have sufficient emergency water supplies and will restock.

Fire extinguisher was last serviced August 2023. Facility was recently inspected by the local fire department which included smoke alarms. No issues noted. Carbon Monoxide detector was tested and operational. Most recent fire drill was conducted June 2023.

Five staff files and two client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator Lindsay Gregori 6017082735 expires 5/27/2024. Medications and medication records were reviewed.

Continued on LIC 809-C
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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Document Has Been Signed on 09/11/2023 12:09 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 09/11/2023 at 11:11 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SARAH'S ADULT RESIDENTIAL CARE
FACILITY NUMBER: 496800668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having disinfectants accessible to clients in care which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/12/2023
Plan of Correction
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Disinfectants were locked immediately and administrator discussed with staff the importance of locking up items that may pose a health and safety risk to clients in care. Deficiency is cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023


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: SARAH'S ADULT RESIDENTIAL CARE
FACILITY NUMBER: 496800668
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)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
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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