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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801090
Report Date: 05/10/2022
Date Signed: 05/10/2022 02:54:17 PM

Document Has Been Signed on 05/10/2022 02:54 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: 23DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Karrie Hanna- Resident Care CoordinatorTIME COMPLETED:
03:00 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. The inspection is focused on the Infection Control procedures and practices of this facility.

Currently twenty-three(23) residents in care, and four(4) residents on Hospice. Facility specializes in dementia care. Hospice care waiver approved for eight (8) residents. Mitigation plan submitted and reviewed by the Department. Fire clearance approval is for twenty-eight (28) non-ambulatory. Fire extinguishers are currently serviced and tagged as required- dated 4/29/21. RCC stated that she will be getting the fire extinguishers serviced before they expire (4/29). There was a sufficient supply of food observed by the LPA. All utilities were observed on and to be working properly. Facility was clean and orderly during the LPA's inspection.

Mitigation policies are in place. All visitors are screened upon entering the facility grounds/building. All visitors have their temperatures taken and answer screening questions. Residents are screened daily, and observed for any changes.Toxins are stored inaccessible and in care. Medications are stored locked making them inaccessible to residents, and staff that do not handle medications. The facility has a large sufficient supply of personal protective equipment (PPE). LPA observed the Resident Care Coordinator and all staff wearing masks during the LPA's inspection.

No deficiencies cited today.
Exit interview conducted with RCC Karrie Hanna.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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