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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801091
Report Date: 05/19/2023
Date Signed: 05/19/2023 12:47:13 PM


Document Has Been Signed on 05/19/2023 12:47 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 SCENICFACILITY NUMBER:
496801091
ADMINISTRATOR:ADALBERTO OJEDA-MENDEZFACILITY TYPE:
740
ADDRESS:819 SCENICTELEPHONE:
(707) 586-3536
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:6CENSUS: 6DATE:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:David Hanna (Licensee)TIME COMPLETED:
01:02 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee David Hanna and Adalberto Ojeda, Administrator. There are residents with a diagnosis of dementia or hospice.

LPA/Administrator initiated a tour of the facility and made the following observations: facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Extra hygiene products and linens were available. Cleaning supplies are locked in supply closets. 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 in medication cabinet. Smoke/Carbon Monoxide detectors located throughout the facility that were tested and operational. Exit doors have auditory alert system that were functional at time of visit. Medications and medication records were reviewed. Fire/disaster drill has been conducted in January 2023. Three out of three fire extinguisher were last inspected July 2023. Three staff files and six resident files were reviewed. Staff does have current required First Aid, CPR certificates and annual required training hours. All residents have their medical assessment and care plans updated within the last 12 months. Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan. Administrator Certificate for Administrator, Adalberto Ojeda #6035345740 expires 5/10/2024. Required postings were observed. Water temperature in resident bathroom measured 112.1 and 114.6 degrees F which are within allowable range of 105 to 120 degrees F.

Licensee agreed to submit updates of the following documents by 5/29/23: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), current lease agreement & copy of Liability Insurance.
No deficiencies cited during today's inspection. Exit interview conducted with Licensee and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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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