496803544-9-30-2024-21-AS-ALOA-D9LUA9-20240930152424

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803544
Report Date: 09/30/2024
Date Signed: 09/30/2024 03:24:40 PM

Document Has Been Signed on 09/30/2024 03:24 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:	LITTLE BIRD ASSISTED LIVING		FACILITY NUMBER:	496803544
ADMINISTRATOR:	FRANCO, KATIE		FACILITY TYPE:	740
ADDRESS:	511 WEBSTER STREET		TELEPHONE:	(707) 559-5793
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94952
CAPACITY:	6	CENSUS: 6	DATE:	09/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Konstanze Franco, Manager Christopher Conradt, Back up Administrator		TIME COMPLETED:	03:45 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	09/30/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently six(6) residents in care. Facility approved/cleared for 6 non-ambulatory, 2 bedridden, and hospice waiver for 3. LPA met with Konstanze Franco (Manager) and Christopher Conradt (Back up Administrator). At approximately 1:10pm, LPA and Manager toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated. Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 116.0 and 116.4 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected June, 2024. Smoke/Carbon Monoxide detectors located throughout the facility are hard wired were tested and operational. Toxins, sharps and other items that could pose threat if available to residents were located in the kitchen and were found to be locked and secured. Emergency food, water supplies, and Personal Protective Equipment are stored in the detached garage. Games along with activities are located in the living room. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. At approximately 1:55pm, LPA conducted review of 5 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file. Continued on LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony Loera	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LITTLE BIRD ASSISTED LIVING	FACILITY NUMBER: 496803544
	VISIT DATE: 09/30/2024

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At approximately 2:20pm, LPA conducted a review of 5 resident records. All records had the required documentation.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCLD within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610- Emergency Disaster Plan (if any changes)
Infection Control Plan (if any changes)

Exit interview conducted with Manager and a copy of this report was provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony Loera	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

LIC809 (FAS) - (06/04)

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