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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801090
Report Date: 06/23/2021
Date Signed: 06/23/2021 04:12:09 PM

Document Has Been Signed on 06/23/2021 04:12 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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: 13DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:David Hanna- AdministratorTIME COMPLETED:
04:20 PM
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Licensing Program Analysts (LPA), Dina Alviso and Karen Lopez. LPA's are conducting an 1 Year Inspection, on 6/23/2021 at approximately 2:40pm and met with Administrator David Hanna, and Resident Care Coordinator Karrie Hanna. The inspection is focused on the Infection Control procedures and practices of this facility.

Currently thirteen (13) residents in care, and two (2) residents on Hospice. Facility specializes in dementia care. Hospice care waiver approved for eight (8) residents. Mitigation plan submitted and approved by the Department on 3/3/21. Fire clearance approval is for twenty-eight (28) non-ambulatory. The Fire Department was out 1/26/21 and did the annual fire inspection; Facility was approved by the fire department, 1/26/21. Fire extinguishers are currently serviced and tagged as required- expires 7/16/20. Administrator stated that he will be getting them re-serviced as required.

Pandemic policies are in place. All visitors are screened upon entering the building; All visitors have their temperatures taken and answer all 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). Administrator and Resident Care Coordinator were wearing masks when LPA's arrived and during the LPA's inspection.

Administrator stated that the facility is following and operating in compliance with their approved mitigation plan, and in compliance with title 22 regulations as required.

No deficiencies cited today.
Exit interview conducted with Administrator David Hanna.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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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