496803290-4-22-2022-21-AS-SHAN-CDQRV3-20220422132053

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803290
Report Date: 04/22/2022
Date Signed: 04/22/2022 01:21:02 PM

Document Has Been Signed on 04/22/2022 01:21 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:	HAZEL HOME		FACILITY NUMBER:	496803290
ADMINISTRATOR:	MILLER, DEBBIE		FACILITY TYPE:	735
ADDRESS:	537 LOS ALTOS CT		TELEPHONE:	(707) 843-4880
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 6		CENSUS: 5	DATE:	04/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Administrator Debbie Miller		TIME COMPLETED:	01:21 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

License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Required – 1 year Infection Control Inspection of the facility. LPA was welcomed by Administrator Debbie Miller for the visit. Facility has 5 clients at this time with 1 at a day program during visit. LPA had returned after Administrator called informing; she had returned to facility from an outing. LPA had temperature checked and logged.

LPA began tour of facility at 12:10 PM with Administrator Debbie Miller. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Hot water temperature of faucets accessible to clients registered within 105 degrees and 120 degrees F. which is within regulation. There was nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days for current census. All medications were locked and inaccessible to clients' in care. All toxins were locked in the garage and inaccessible to clients. Emergency supplies are also kept in the garage. Laundry room contains enough linens for clients in care. All smoke alarms were functional and carbon Monoxide detectors were present. Required postings were observed. Sufficient lighting was present in common areas, hallways, and client rooms. Required furniture was also present in client rooms. Fire extinguished last charged November 11, 2021.

Infection Controle:

Facility has submitted a mitigation program plan that was approved, 5/18/2021. All staff and visitors check in and log temperatures and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. The facility has a sufficient supply of personal protective equipment (PPE) stored in laundry room. Staff had all PPE training required; they are still working on getting N95 Fit Tested. All but 1 staff who has a religious exemption on file and clients have been fully vaccinated and received their COVID booster shots or are waiting for the six-month time date.

Continued on LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HAZEL HOME	FACILITY NUMBER: 496803290
	VISIT DATE: 04/22/2022

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
26
27
28
29
30
31
32

LPA reviewed Licensing Information System (LIS) with designee who stated that is correct and updated at this time; no need to change any of the information, just add Mobile phone (707) 217-1922. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1^st Aid certification for staff.

Administrator Certificate for Debbie Miller – waiting to receive updated -LPA observed completed required trainings and check stubs sent.

No deficiencies cited today.
Exit interview conducted with Licensee/Administrator Debbie Miller.

LPA requested additional updated forms to be sent to CCL by May 10, 2022:

LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Client Cash Resources
LIC 402 Surety Bond
LIC610 Emergency Disaster form

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2