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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802057
Report Date: 05/31/2024
Date Signed: 05/31/2024 02:32:18 PM

Document Has Been Signed on 05/31/2024 02:32 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/
DIRECTOR:
CLIFT, JOLENEFACILITY TYPE:
735
ADDRESS:454 UMLAND DRIVETELEPHONE:
(707) 544-6575
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 4CENSUS: 2DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Jolene Clift (Licensee)TIME VISIT/
INSPECTION COMPLETED:
02:47 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Licensee/Administrator Jolene Clift. Fees are current. Clients were attending day program during visit. Contact information was reviewed. Required postings were observed.

LPA/Licensee initiated a tour of the facility at 1:30 pm and observed the following: Facility was a comfortable temperature with thermostat in hallway reading at 70 degrees F. Passageways were free from obstructions. Client rooms are furnished per regulation. Water temperature in client bathroom read at 107.6 which is 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 October, 2023. Facility has a fire pull system. The last fire department visit was conducted on 5/14/24. Smoke detectors and carbon monoxide are hard wired and were operational at time of inspection. Most recent Fire/Disaster drill was conducted 5/14/24.

LPA initiated file review at 1:45pm. Two client and two staff files were reviewed. First aid certificates for staff are current. Administrator Certificate for Jolene Clift, 6011501735 expires 8/30/24. Medications and medication records were reviewed. Cash resources and records were also reviewed.

Licensee agreed to submit updates of the following documents by 6/7/24: LIC500 (Personnel Report), LIC400 (cash affidavit for clients), control of property and surety bond.

No deficiencies cited during this inspection.
Exit interview was conducted with licensee and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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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