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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801205
Report Date: 01/20/2023
Date Signed: 01/20/2023 02:57:42 PM


Document Has Been Signed on 01/20/2023 02:57 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:HOEN'S CARE HOMEFACILITY NUMBER:
496801205
ADMINISTRATOR:ALCONES, LILY O.FACILITY TYPE:
740
ADDRESS:1618 MARIPOSA DRIVETELEPHONE:
(707) 573-8922
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 6DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Designated Administrator, Arthur AlconesTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 01/20/2023 to conduct a required 1 - year inspection. This inspection is focused on the infection control practices and procedures of this care facility. LPA met with designated administrator, Arthur Alcones.

LPA toured building and grounds which were clean and in good repair. Exits and walkways were clear from obstructions. COVID postings and screening materials were present at the front entrance. High touch surface areas are disinfected daily. Bathrooms had necessary grab bars and nonslip flooring. Facility has a sufficient amount of perishable and nonperishable food. Sufficient personal protective equipment was available to support a resident in isolation. Toxins were locked and secured. Medications were locked and secured. Fire extinguishers were charged and current. Staff have been given infection control training. Staff and residents are fully vaccinated. LPA and licensee reviewed what a comprehensive inspection entails and best practices to maintain compliance.

LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection:

LIC 308 Designation of Facility Responsibility
LIC 610 Emergency Disaster Plan
LIC 500 Personnel Report
LIC 9020 Client Roster
Evidence of Liability Insurance

Exit interview conducted with Arthur Alcones, copy of this report sent to his email. No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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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