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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801432
Report Date: 09/25/2023
Date Signed: 09/25/2023 01:27:13 PM

Document Has Been Signed on 09/25/2023 01:27 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:SARAH'S DUTTON AVENUE MANORFACILITY NUMBER:
496801432
ADMINISTRATOR:GOMES, RAQUELFACILITY TYPE:
735
ADDRESS:803 NORTH DUTTON AVE.TELEPHONE:
(707) 526-4081
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 4DATE:
09/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Raquel Gomes (Administrator)TIME COMPLETED:
01:42 PM
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Licensing Program Analysts (LPAs) Cuadra and Coppo arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Raquel Gomes. Clients are attending to day program.

LPA initiated a tour of the facility 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 bathrooms measured at 118.1 and 119.7 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Cabinets containing cleaning supplies located in the garage were locked. Facility has at least two days of perishable foods and one week of non-perishable foods. Medications were centrally stored and locked. Required postings were observed.

Fire extinguisher was last inspected July, 2023. Smoke detectors are hardwired and maintained by a vendor. Most recent service was conducted August, 2023. Carbon monoxide detector was tested and operational. Most recent fire drill was conducted 6/27/2023. Exit Auditory alarms were on and working during visit. Medications and medication records were reviewed. Cash Resources were reviewed.

File review was initiated at 12:00 pm. Three staff files and four client files were reviewed. Staff have required First Aid certificates. Administrator Certificate for Raquel Gomes, 6036743735, expires on 8/31/23. Administrator was able to provide proof that the documents were sent to CCL Administrator's unit.

Administrator provided updated documents during visit: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Emergency Disaster Plan (LIC610E).

Administrator agreed to provide the following documents by 10/6/23: updated Surety Bond & control of property. Exit interview conducted with Administrator and a copy of this report was given. No deficiencies cited during this inspection
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2023
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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