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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801090
Report Date: 06/27/2023
Date Signed: 06/27/2023 03:37:10 PM


Document Has Been Signed on 06/27/2023 03:37 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:HANNA HOUSE RIDLEYFACILITY NUMBER:
496801090
ADMINISTRATOR:HANNA, DAVIDFACILITY TYPE:
740
ADDRESS:1840 RIDLEY AVENUETELEPHONE:
(707) 591-0980
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:28CENSUS: 27DATE:
06/27/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:David Hanna-AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst(LPA), Alviso conducted a Required - 1 Year Inspection, and met with Resident Care Coordinator(RCC), Karrie Hanna.

Currently twenty-seven(27) residents in care, and one(1) resident on Hospice. Facility specializes in dementia care. Hospice care waiver approved for eight (8) residents. Facility has a required infection control plan, which is part of the operation plan.

Fire clearance approval is for twenty-eight (28) non-ambulatory. All exits were cleared and free of obstruction. Fire extinguishers(5) are currently serviced and tagged as required- expires 7/14/23. Fire Department inspection completed on facility's fire panel on 3/16/23, passed inspection.

There was a sufficient supply of perishable and non-perishable food observed by the LPA. All utilities were observed on and to be working properly. Facility had a supply of food, water, and emergency items, to meet the 72 hour shelter in place requirement. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed. All bathrooms had grab bars, and non-slip flooring/mats for use as needed. Hot water was checked at 117.1F. which is within regulation of no lower than 105.F , and no higher than 120.F. Toxins are stored inaccessible and in care. Medications are stored locked making them inaccessible to residents, and staff that do not handle medications.

Continued on LIC809C....
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
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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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: HANNA HOUSE RIDLEY
FACILITY NUMBER: 496801090
VISIT DATE: 06/27/2023
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The LPA reviewed six(6) staff files, including training. All staff have criminal record clearance as required. The LPA reviewed six(6) resident files, including medication records.

LPA is requesting the following documents be updated and submitted by 7/27/23:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610-Emergency Disaster Plan
Copy of Current Liability Insurance
Infection Control Plan- if any updates- please ensure to date and sign last page

No deficiencies cited today.
Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC809 (FAS) - (06/04)
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