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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803576
Report Date: 08/31/2023
Date Signed: 08/31/2023 03:15:29 PM


Document Has Been Signed on 08/31/2023 03:15 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:SLEEPY HOLLOW ASSISTED LIVINGFACILITY NUMBER:
496803576
ADMINISTRATOR:ARTHUR ALCONESFACILITY TYPE:
740
ADDRESS:3707 SLEEPY HOLLOW DRIVETELEPHONE:
(707) 953-2161
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:6CENSUS: 6DATE:
08/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Licensee, Arthur AlconesTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Licensee, Arthur Alcones arrived later.

LPA initiated a tour of the facility around 11:10am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 110 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in the garage. Personal Protective Equipment is stored in a room in the facility.

Fire extinguishers were last serviced September 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 8/2023.

Three staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Arthur Alcones expires 8/23/2024. Medications and medication records were reviewed. Training records were also reviewed.

Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SLEEPY HOLLOW ASSISTED LIVING
FACILITY NUMBER: 496803576
VISIT DATE: 08/31/2023
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Continued from LIC809

Licensee/Administrator to submit updates of the following documents by 9/30/2023:


LIC 500 Personnel Summary
Copy of Liability Insurance
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC809 (FAS) - (06/04)
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