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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803290
Report Date: 04/20/2023
Date Signed: 04/20/2023 11:41:17 AM

Document Has Been Signed on 04/20/2023 11:41 AM - 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 HOMEFACILITY NUMBER:
496803290
ADMINISTRATOR:MILLER, DEBBIEFACILITY TYPE:
735
ADDRESS:537 LOS ALTOS CTTELEPHONE:
(707) 843-4880
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 5DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Debbie Miller, Licensee/Administrator & Robert "Tony" Miller, Administrator TIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA), Shannan Hansen arrived unannounced to conduct a Required Annual inspection of facility. LPA met with Debbie Miller, Licensee/Administrator and Robert Miller, Administrator. There are 5 clients that reside at facility but all were either at day programs or in the community at time of visit.

At 8:45 AM LPA toured the facility with Licensee Debbie Miller. Building and grounds were found to be clean and in good repair. The exits were unobstructed. 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. Medications were centrally stored and inaccessible to clients in care. Medication and Medication record review was completed. 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. Fire extinguisher was last inspected 11/23/2022. Required postings were observed. Sufficient lighting was present in common areas, hallways, and client rooms. Required furniture was also present in client rooms. Disaster Drills are conducted quarterly, with the last drill conducted 12/15/2022.

LPA began file review at 9:45 AM. LPA reviewed 5 of 5 client files and 4 staff files. All client records were complete. Client Cash resources are separated and not co-mingled with other facility funds. Staff had required criminal record clearance and First Aid Certification. Administrator Certificates were current with expiration dates of (Debbie Miller 2/3/2024 & Robert Miller 5/1/2023).

No deficiencies were observed in the areas inspected. No citations issued during today’s visit.

Continue on LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HAZEL HOME
FACILITY NUMBER: 496803290
VISIT DATE: 04/20/2023
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LPA requested additional updated forms to be sent to CCL by 5/4/2023:

LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Client Cash Resources
LIC 402 Surety Bond
LIC610 Emergency Disaster form
Control of Property
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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