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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801929
Report Date: 10/25/2022
Date Signed: 10/25/2022 11:41:27 AM


Document Has Been Signed on 10/25/2022 11:41 AM - 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:FRIENDS HOUSEFACILITY NUMBER:
496801929
ADMINISTRATOR:CARENBAUER, JACLYNFACILITY TYPE:
741
ADDRESS:684 BENICIA DRIVETELEPHONE:
(707) 538-0152
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:145CENSUS: 80DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jaclyn Carenbauer-AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a Required 1-Year inspection, at approximately 9:45am on 10/25/22, and met with Administrator Jaclyn Carenbauer. This inspection is focused on the Infection Control procedures and practices of this facility.

LPA was screened for COVID symptoms by the Administrator, temperature taken, and all information was logged. LPA observed temperature logs, visitor sign-in sheet, and COVID postings, masks available, and sanitizer for all to use when entering the facility.

LPA conducted walk through of the facility with administrator and observed it to be clean and orderly. Infection Control Plan was submitted to Licensing Agency as required.

Facility was at a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility for all to use as needed. LPA observed PPE supplies available, and used as required by all staff. PPE supplies are sufficient. Food supply, perishable and non-perishable are sufficient. Fire extinguishers were all tagged and serviced as required-expires 12/9/22. The Administrator will ensure the fire extinguishers are all serviced and tagged before they expire.

Medications are locked and inaccessible to residents in care. All medications are locked and inaccessible to residents in care. Only staff that are trained to handle medications have access to the medications. Sufficient supply of cleaners, paper products, and hygiene products. Assisted living residents all have private rooms at this time due to choice and/or current census of residents needing care services provided to them. All outside/inside walkways/hallways the LPA walked through and observed, were all clear for resident use when ambulating through the community.

No deficiencies cited today.
Exit interview conducted with the administrator, Jaclyn Carenbauer.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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