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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801432
Report Date: 09/06/2024
Date Signed: 09/06/2024 03:51:17 PM

Document Has Been Signed on 09/06/2024 03:51 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/
DIRECTOR:
GOMES, RAQUELFACILITY TYPE:
735
ADDRESS:803 NORTH DUTTON AVE.TELEPHONE:
(707) 526-4081
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 3DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Raquel Gomes, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analysts (LPA) Hansen arrived unannounced to conduct an Annual Required Inspection and was greeted by staff Dawn who contacted Administrator, Raquel Gomes that arrived shortly after. Clients were attending 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. 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 8, 2024. Smoke detectors are hardwired and maintained by a vendor. Most recent service was conducted August, 2024. 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.
File review was initiated at 2:15 PM with three client files that contained all current records required. LPA was unable to finish Annual inspection of Staff files and medication review and will return at a later date.

No deficiencies observed during today's inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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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