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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803001
Report Date: 01/18/2024
Date Signed: 01/18/2024 02:32:18 PM


Document Has Been Signed on 01/18/2024 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: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:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Sarah Araya (Administrator)TIME COMPLETED:
02:47 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Administrator, Sarah Araya. Two residents were home during the visit.

LPA/staff initiated a tour of the facility at 12:00pm and observed the following: Facility was a comfortable temperature and pathways were free from obstructions. Resident rooms were furnished per regulation. Extra linens and hygiene products were available. Hot water temperature in resident's bathrooms measured at 107.8 and 108.2 F which is within allowable range of 105 to 120 degrees F. Medications were centrally stored and locked at time of inspection. Toxins are located in a locked cabinet in the garage. At least two days of perishable and one week of nonperishable food was available. Fire extinguishers were last serviced January 2024. Smoke detectors and carbon monoxide detector throughout the facility were tested and operational. Exit doors have auditory alert system that were functional at time of visit. Last disaster drill was conducted on 11/30/23. Medication and medication records were reviewed. Required postings were observed. Annual fees current.

LPA conducted file review at 12:30 PM. Four staff files and four resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Sarah Araya 6010373740 expires 4/10/2025. Training records were reviewed. Four out of four resident's files have current medical assessments and care plans. Facility handles cash resources for three out of four residents and maintains documentation. Cash on hand is covered by the Surety Bond.

Administrator to submit updates of the following documents by 1/29/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), copy of Liability Insurance & surety bond.
No deficiencies cited during today's inspection. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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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