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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803505
Report Date: 05/04/2023
Date Signed: 05/04/2023 02:36:06 PM


Document Has Been Signed on 05/04/2023 02:36 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:TAKING THE JOURNEY LLCFACILITY NUMBER:
496803505
ADMINISTRATOR:DOSS, KISAFACILITY TYPE:
740
ADDRESS:512 CASA VERDE CIRCLETELEPHONE:
(707) 981-8751
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 5DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kelly Eriksen, LicenseeTIME COMPLETED:
02:45 PM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required Annual inspection of the facility. LPA was welcomed by Licensee/Administrator Kelly Eriksen. There is a total of 5 residents at the facility, currently non with a diagnostic of dementia. There are 2 residents currently on Hospice.

LPA toured the facility on 5/4/2023 at 10:20 AM with Kelly Eriksen Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices which were activated and working properly at the time of the visit. Fire Extinguisher was found to be last charged on 12/7/2022 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 113.3 degrees F and 118 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored locked under the sink in a kitchen cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307.

A review of five resident & five staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 1:00 PM on 5/4/2023 and learned that 5 of 5 residents have an updated reappraisal/needs & care plan, TB and physician’s assessments on file as required by Title 22 Regulation. Medications were centrally stored in locked cabinets in the facility office by living room of the facility. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 5/4/2023 at 1:20 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.



Continue on LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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: TAKING THE JOURNEY LLC
FACILITY NUMBER: 496803505
VISIT DATE: 05/04/2023
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LPA reviewed a sample of staff records at 1:40 PM on 5/4/2023 and learned that all facility staff present and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff at the facility have received the additional training requirements. LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed. Kisa Doss Administrator Certificate # 6007381740 expires on 3/7/2023.

LPA reviewed Licensing Information System (LIS) with Licensee Kelly Eriksen who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills have been conducted quarterly with the last one being conducted on 2/27/2023. In addition, facility is ensuring staff is trained monthly.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update the following documents by 5/19/2023:



LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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