<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801090
Report Date: 06/27/2024
Date Signed: 06/27/2024 05:10:26 PM


Document Has Been Signed on 06/27/2024 05:10 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: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: 24DATE:
06/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:David Hanna-AdministratorTIME COMPLETED:
05:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Alviso, conducted a Required - 1 Year Inspection, and met with Administrator David Hanna and Resident Care Coordinator (RCC) Karrie Hanna.

Currently twenty-four (24) 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 plan of operation. Facility has a required emergency disaster plan.

LPA reviewed six (6) resident files. All files were complete.
LPA reviewed six (6) staff files. All staff had criminal record clearance as required. All staff had first aid, and cpr certification as required. Staff had required training.

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. Sufficient food supply. Sufficient cleaner/disinfectants, personal protective equipment (PPE), paper products, furnishings, and linens. Sufficient lighting in hallways, bathrooms, resident rooms, and common areas. All postings were up and visible. Medications were locked up and inaccessible to residents in care. All cleaners/disinfectants were locked up and inaccessible to residents in care.

LPA is requesting the following documents be updated and submitted by 7/27/24.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610-Emergency Disaster Plan- if any updates submit copy- please ensure to date and sign last page
Copy of Current Liability Insurance
Infection Control Plan- if any updates submit copy- please ensure to date and sign last page

No deficiencies cited today.
Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1