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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801251
Report Date: 02/29/2024
Date Signed: 02/29/2024 01:43:16 PM

Document Has Been Signed on 02/29/2024 01:43 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:
02/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Cathy Olds (Licensee)TIME COMPLETED:
01:58 PM
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Licensing Program Analyst (LPA) Cuadra, arrived unannounced to conduct an Annual Required Inspection and met with Licensees Cathy Olds and Dave Olds arrived later.

LPAs initiated a tour of the facility at 12:30 pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in client's bathroom measured at 108. and 106.7 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Cabinets containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Last disaster drill conducted on February 19, 2024. Fire extinguisher was last inspected 9/2023. Smoke detectors located throughout the facility were tested and operational. Carbon monoxide detector was tested and operational.

File review was initiated at 12:45 pm. Two staff files and three client files were reviewed. Staff have required First Aid certificates. Administrator Certificates for Licensees Catherine E. Olds #6020256735, expires 11/8/2025. Medications and medication records were reviewed. Cash resources and documents were reviewed.

Licensee/Administrator to submit updates of the following documents by 3/8/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E) and Surety Bond.
No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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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