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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803290
Report Date: 04/16/2024
Date Signed: 04/16/2024 10:18:12 AM

Document Has Been Signed on 04/16/2024 10:18 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/
DIRECTOR:
MILLER, DEBBIEFACILITY TYPE:
735
ADDRESS:537 LOS ALTOS CTTELEPHONE:
(707) 843-4880
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 5DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:45 AM
MET WITH:Debbie Miller, Licensee/Administrator & Robert "Tony" Miller, DegisneeTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA), Shannan Hansen arrived unannounced to conduct an Annual inspection of facility. LPA met with Debbie Miller, Licensee/Administrator and Robert "Tony" Miller, designee. There are 5 clients that reside at facility, some were either leaving for programs or were already out in the community at time of visit.

At approximately 8:00 AM LPA toured the facility with Administrator/designee Robert Miller. Building and grounds were found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulations. Hot water temperature of faucets accessible to clients registered within regulations of 105 degrees F and 120 degrees F. Medications were centrally stored and inaccessible to clients in care. Medication and Medication record review was completed. Toxins are locked in garage, 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 and tested, in working order. Fire extinguisher was last inspected 12/04/2023. 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 01/07/2024.

At approximately 8:45 AM, LPA reviewed 5 of 5 Client files and 3 of 3 staff files, which were all found to be well organized, thorough and contained the required documentation. Staff have required First Aid certificates and Criminal Record Clearance. P&I monies were documented, secured and not commingled. Administrator Certificates were current with expiration dates of (Debbie Miller 2/3/2024 observed proof of submission & Robert Miller 5/1/2025).

Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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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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: 04/16/2024
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LPA requested additional updated forms to be sent to CCL by 5/4/2024:

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

No deficiencies were observed in the areas inspected. No citations issued during today’s visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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