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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803001
Report Date: 12/09/2022
Date Signed: 12/09/2022 01:10:42 PM

Document Has Been Signed on 12/09/2022 01:10 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SARAH'S RETIREMENT HOME FOR DD SENIORSFACILITY NUMBER:
496803001
ADMINISTRATOR:ARAYA, SARAHFACILITY TYPE:
740
ADDRESS:791 MCCONNELL AVENUETELEPHONE:
(707) 528-6623
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 4DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Sarah ArayaTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with caregiver, Rose Taylor. Administrator, Sarah Araya arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was asked to sign in and answer a questionnaire with standard Covid-19 screening questions. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility around 12:10pm and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected twice per day. Facility continues to screen staff and residents and maintains documentation.

Facility has a designated visitation area outside and is allowing for visitation inside per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment (PPE).

Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, gloves and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced December 2021. Smoke detectors and Carbon Monoxide detector were tested and operational.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SARAH'S RETIREMENT HOME FOR DD SENIORS
FACILITY NUMBER: 496803001
VISIT DATE: 12/09/2022
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Continued from LIC809C

Facility has submitted their Emergency Disaster Plan, Infection Control Plan and Mitigation Plan. LPA and Caregiver discussed facility's ability to transport residents in case of evacuation.

Licensee/Administrator to submit updates of the following documents by 1/09/2023:



Proof of Liability Insurance
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond
LIC 9020 Register of Facility Residents
LIC 610 Emergency Disaster Plan (review and update if changes)

No deficiencies cited during inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
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