496803001-1-23-2025-21-AS-DALO-DD7RTQ-20250123121842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803001
Report Date: 01/23/2025
Date Signed: 01/23/2025 12:18:47 PM

Document Has Been Signed on 01/23/2025 12:18 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 SENIORS		FACILITY NUMBER:	496803001
ADMINISTRATOR/ DIRECTOR:	ARAYA, SARAH		FACILITY TYPE:	740
ADDRESS:	791 MCCONNELL AVENUE		TELEPHONE:	(707) 528-6623
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Sarah Araya-Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a Required -1 Year inspection, on 1/23/25 at approximately 9:20am, and met with Sarah Araya, Administrator. LPA observed two caregivers on duty during the inspection. Currently there are four (4) clients in care. The facility has a fire clearance for six (6) non-ambulatory residents. Facility has a required infection control plan, and a required emergency disaster plan. Hospice waiver approval is for two (2) residents. Per record review, facility is holding quarterly emergency disaster drills as required. Fire extinguisher was serviced and tagged as required. LPA reviewed four (4) resident files. Medications, and medication records were reviewed. LPA reviewed four (4) staff files, including training. LPA toured the facility with the Administrator. Hot water was checked at 110.4 degrees Fahrenheit, which is within regulation. LPA observed sufficient food supply. LPA observed sufficient supply of paper products, cleaners/disinfectants, hygiene products, and personal protective equipment (PPE). Facility had sufficient lighting in resident rooms, common areas, bathrooms, and hallways for resident use. Bathrooms had required grab bars, and non-slip flooring/mats in showers/bathtubs for resident use. Medications are stored in a closet that is locked, making medications inaccessible to residents in care. Cleaners/disinfectants are kept locked and inaccessible to residents in care. LPA discussed regulation regarding fire clearance and ensuring all fire exits are fully cleared/unobstructed at all times as required. Administrator stated their understanding. Administrator had staff move the table from blocking part of the slider door exit during the inspection. Continued on LIC809C..

Bethany Moellers	TELEPHONE: (707) 588-5040
Dina Alviso	TELEPHONE: (707) 588-5082
	DATE: 01/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

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: 01/23/2025

NARRATIVE

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Continued from LIC809..

LPA is requesting the following documents by 2/23/25.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate.

LPA observed the following deficiency::

LPA observed a made-up rollaway bed in an open storage room in the facility's back room/ common area. S1 told the LPA that the bed was staffs. The staff that come in and work nights use the bed, it is brought out into the common area. LPA discussed regulation regarding facility bedrooms, common areas, and awake night staff versus sleeping night staff. This deficiency will be cited, 87307(a) Personal Accommodations and Services- Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator Sarah Araya
Appeal Rights provided to the Administrator.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2025 12:18 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87307(a) Personal Accommodations and Services- Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed a made-up rollaway bed stored in an open storage room in the facility’s common area. S1 told the LPA that the bed was staffs. The staff that come in and work nights use the bed, it is brought out into the common area. LPA discussed regulation regarding facility bedrooms, common areas, and awake night staff versus sleeping night staff, the licensee did not comply with the section cited above which poses/posed a personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Licensee to ensure that no staff are sleeping in the common areas of the facility; Submit how the facility will ensure awake night staff are not sleeping in common areas and/or using rollaway beds and furnishings to sleep in common areas. Submit plan of awake night staff schedule, copy of schedule, and staff duties while on night/noc shift at the facility. POC due 1/31/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Dina Alviso	TELEPHONE: (707) 588-5082
	DATE: 01/23/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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