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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802057
Report Date: 05/12/2023
Date Signed: 05/12/2023 01:33:32 PM

Document Has Been Signed on 05/12/2023 01:33 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:HARTWIG HOUSEFACILITY NUMBER:
496802057
ADMINISTRATOR:CLIFT, JOLENEFACILITY TYPE:
735
ADDRESS:454 UMLAND DRIVETELEPHONE:
(707) 544-6575
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 4CENSUS: 2DATE:
05/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Jolene Clift (Administrator)TIME COMPLETED:
01:48 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Administrator Jolene Clift. At the time of visit, all clients were attending to Day Program.

Upon arrival, LPA confirmed with Licensee that they are following current Covid19 and masks guidance. LPA/Administrator initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and pathways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathrooms read at 108 which are within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable foods were available. Toxins are locked in a cabinet under the kitchen sink. Fire extinguishers were last inspected April 2023. Smoke detectors and carbon monoxide detector located throughout the facility were tested and operational. Most recent Fire/Disaster drill was conducted 2/1/23. Facility has a fire pull system and it was last inspected by Santa Rosa Fire Department on April 20, 2023. Required postings were observed. Emergency supplies were observed including flashlights and water. Facility does have a current activity and menu calendar.

LPA initiated a file review at 12:00 pm. Two client and two staff files were reviewed. Clients records have updated care plans on file. First aid certificates for staff are current. Administrator Certificate for Jolene Clift 6011501735, expires 8/30/2024. Medications and medication records were reviewed. Cash resources and documentation were reviewed. Medications are centrally stored and locked. First aid kit was fully stocked

LPA obtained updates of the following documents: LIC500 (Personnel Report), LIC400 (cash affidavit for clients) and surety bond.

No deficiencies cited during today's inspection. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
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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