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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801251
Report Date: 02/09/2023
Date Signed: 02/09/2023 02:42:16 PM

Document Has Been Signed on 02/09/2023 02:42 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:OLDS HOMEFACILITY NUMBER:
496801251
ADMINISTRATOR:OLDS, CATHERINEFACILITY TYPE:
735
ADDRESS:936 LANGEBURG ST.TELEPHONE:
(707) 526-4884
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 4CENSUS: 3DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Catherine Olds (Licensee)TIME COMPLETED:
02:57 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) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee Catherine Olds. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Commonly touched surfaces are disinfected at least twice per day. Facility does perform daily screening of staff and residents and documents it. Facility will be allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control, donning and doffing of Personal Protective Equipment PPE and have been N95 fit tested. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. All staff and clients have been vaccinated. Last disaster drill conducted on January 2023. Fire extinguishers was last serviced September 2022. Smoke Detectors and Carbon Monoxide detector were operational. All clients do not attend to in-person day program, but they do attend to online classes daily and the facility provides activities for them.

Facility will provide copies of the following documents by 2/23/23: Designation of Responsibility (LIC308), Affidavit Regarding Client Cash Resources (LIC400), Surety Bond, Personnel Report (LIC500) and LIC 610 Emergency Disaster Plan (if any changes).

Exit interview conducted with Licensee and a copy of this report was given.
No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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